State/Regional Affiliate Program Speaker Requests

State/Regional Affiliate Program Speaker Requests

Please complete the following information pertaining to your meeting. This information is critical in helping to identify a speaker. Note: This form is for use by ASCO's State/Regional Affiliates only.

State Society Name*

Select

Please provide the name of this event.*

Primary Event Contact Information

First and Last Name*

Phone Number*

Phone

Email*

Meeting Date(s)/Time

Day 1*

First day of the meeting

Start Time*

End Time*

Final Day

Last day of meeting

Start Time

Is it a virtual event?

Check if yes.

End Time

Meeting Location

Venue Name*

Street Address*

Include city, state, and ZIP code

Venue Phone Number*

Phone

If a State/Regional Affiliate initiates a speaker request, it is that society’s responsibility to cover the speaker(s)’ hotel accommodations for a maximum of two hotel nights. Any additional hotel nights will be reviewed and reimbursed by ASCO if necessary. A hotel confirmation number (if applicable) should be provided to the speaker at least two weeks in advance of the meeting date.

Will you be making hotel arrangements for the speaker?*

Check if yes.

Lodging Comments

Will you be providing ground transportation for the speaker?

Check if yes. If not, please indicate the best method of traveling to the hotel and event below.

Transportation Information

Speaker

Preferred Speaker Name (if known)

Speaker's Engagement Date*

Start Time*

End Time*

Presentation Details

Please indicate below what topic(s) you want the speaker to cover at your meeting.

Target Audience

If Other, please describe below.

Estimated total number of attendees*

CME Application

Do you plan to provide CME credits to attendees?

Check if yes.

Audio/Visual

Will the meeting room be equipped for PowerPoint projection?*

If so, please select the available equipment below.

Projector/Screen

Laptop

By when do you need the PowerPoint presentation?*

By when do you need any handouts/materials for distribution?*

By when do you need the speaker(s)'s bio?*

Additional Comments

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