ABHMS Staff Speaker Request

ABHMS Staff Speaker Request

Please complete this form to request a member of ABHMS' staff to speak at your event or gathering. Please complete one form per event.

Your Information & Event Information

Prefix

Your First Name*

Your Last Name*

Your Email Address*

Event Name*

Host Organization*

Brief Description, Theme or Focus of Event*

Event Start Date*

Event End Date*

Expected Number of Attendees*

Geographic Location & Event Venue (if known)*

Speaker Request Information

Requested Speaker*

To view staff list and bios, please visit https://abhms.org/about-us/staff/.

Select or enter value

Which of the following roles are you wanting the requested speaker to fill?*

Select

Please specify what other role you would like the requested speaker to fill.*

Additional Requested Speaker

https://abhms.org/about-us/staff/

Select or enter value

Which of the following roles would you like the requested speaker to fill?

Select

Please specify what other role you would like the requested speaker to fill.

Additional Requested Speaker

Select or enter value

Which of the following roles would you like the requested speaker to fill?

Select

Please specify what other role you would like the requested speaker to fill.

Additional Requested Speaker

Select or enter value

Which of the following roles would you like the requested speaker to fill?

Select or enter value

Please specify what other role you would like the requested speaker to fill.

Additional Requested Speaker

Select or enter value

Which of the following roles would you like the requested speaker to fill?

Select

Please specify what other role you would like the requested speaker to fill.

Will honorarium be provided?*

Select or enter value

Which of the following travel and attendance expenses are you able to cover for the requested speaker either through direct provision or reimbursement?*

Please select all that apply.

Select or enter value

Please specify other travel and attendance expenses

Will there be an opportunity to promote ABHMS at this event?*

Select or enter value

Please specify what other opportunities for ABHMS promotion are available for this event.

Additional Comments

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