Defeat MSA Alliance Presenter Agreement Speaker Name(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Title Prenom (First Name) Middle Name Family Name / Surname / Last Name Presentation Topic Area (if you presented previously, please choose another area unless you are planning an update) Possible Contribution of Environmental Risk Factors in MSA (or Causative Factors/Pathology of MSA) New Diagnostic Methods for MSA New Diagnostic Criteria for MSA Clinical Trials and New Therapeutic Approaches in MSA Possible Surgical Therapies in MSA (including Spinal Cord Stimulator and Re-evaluation of DBS?) Multidisciplinary Approach to Treat MSA (MSA Clinic) Biomarkers or New Research (Update) Special Topics: orthostatic hypotension, non motor symptoms, infections, autonomic symptoms, constipation, speech, swallowing, advanced cases care (pegs, etc), advanced directives, erectile dysfunction, ataxia, dystonia, camptocormia, RBD, sleep apnea, pisa syndrome, head & foot drop, etc. Other (Write Topic in space provided below – Thank you!) If you have different presentation topic, please fill in the information below:Postal Address (Professional Institution Address)(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Speaker Email Address(Required) Speaker Phone Number(Required)Speaker's Biography/Profile (required for booklet/website)Max. file size: 640 MB.A profile or biography for the conference booklet or press release is recommended. All file formats are permitted.Speaker's Photo (required for booklet/website)Max. file size: 6 GB.A photo for press release and conference booklet is recommended. All file formats are permitted.Exhibits/Slides/PowerPoint Drop files here or Select files Accepted file types: jpg, gif, png, pdf, ppt, Max. file size: 1 GB, Max. files: 10. Please upload any exhibits, slides or PowerPoint you will use in your presentation.Primary Presentation Title (If not in English, please provide the title in both languages)(Required)What is the title of your primary presentation?Language of Presentation(Required)In what language will you be presenting?Second Presentation Title (If not in English, please provide both languages)What is the title of your second presentation? (If you have two presentations)Language of Second PresentationIn what language will you be presenting?Views and Conclusions are My Own(Required) Views and Conclusions are My Own(Required)I agree to advise the audience that the views and conclusions presented in my talk are my own and do not represent the views of Defeat MSA Alliance (USA) or any affiliated charities in the MSA United International Consortium. I will not promote specific labs, researchers, companies or other entities who are unaffiliated with MSA United Consortium.Disclosures(Required) Disclosures(Required)I will disclose whether I am being compensated by a pharmaceutical company and/or a similar company organization.No Medical Advice(Required) No Medical Advice(Required)I agree not to give any medical advice. I will advise viewers to contact their medical services provider for any questions about diagnosis or treatment.Permission to post video(Required) Permission to post video(Required)I give permission to Defeat MSA Alliance and MSA United International Consortium to edit and post a video of my presentation on social media and to use my image and likeness.Message to Conference Coordinator (optional):