Speaker request form

Event title *

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Name of organization hosting event *

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Is the organization a non-profit? *

Yes/No

Enter venue name and address *

Address Line 1

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

Start time *

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End time *

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Amount of speaker fee? *

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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 *

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Last

Contact name

Organization name and location *

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Office number *

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Cell number *

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Email *

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Please give a brief description of your organization *

Presentation details

Topic of presentation *

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Type of presentation *

Length of requested presentation *

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Audience and key participants *

First Choice
Second Choice
Third Choice

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Audience size *

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Audio visual capabilities *

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

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