Speaker request form

Enter event title
Enter name of organization
Enter event location
Enter start time
Enter end time
Enter the amount for the speaker fee
Yes/No (Please note: Concerned Doctors does not cover travel expenses for requested speakers)
Y/N (Please note: Press releases that include Concerned Doctors or their members, must have prior approval)
Please state the purpose of this event
Contact name
Enter office number
Enter cell number
Enter your email address
Presentation details
Enter topic of presentation
Choose on of the time slots below
Select from the following
Choose from the estimated size of audience below
Will you provide audio visual for the speaker? Yes or no