Speaker request form – Concerned Doctors

Event title *

Enter event title

Name of organization hosting event *

Enter name of organization

Is the organization a non-profit? *

Yes/No

Enter venue name and address *

Address Line 1

Address Line 2

City

State

Zip Code

Enter event location

Event date (must be at least 14 days out and is based on availability *

Start time *

Enter start time

End time *

Enter end time

Amount of speaker fee? *

Enter the amount for the speaker fee

Travel expenses covered *

Yes/No (Please note: Concerned Doctors does not cover travel expenses for requested speakers)

Expected media coverage *

Y/N (Please note: Press releases that include Concerned Doctors or their members, must have prior approval)

What is the purpose of this event? *

Please state the purpose of this event

Contact Person *

First

Last

Contact name

Organization name and location *

Address Line 1

Address Line 2

City

State

Zip Code

Office number *

Enter office number

Cell number *

Enter cell number

Email *

Enter your email address

Please give a brief description of your organization *

Presentation details

Topic of presentation *

Enter topic of presentation

Type of presentation *

Length of requested presentation *

Choose on of the time slots below

Audience and key participants *

First Choice
Second Choice
Third Choice

Select from the following

Audience size *

Choose from the estimated size of audience below

Audio visual capabilities *

Will you provide audio visual for the speaker? Yes or no