Speakers Bureau Request Form Speakers Bureau Request Form Please complete the following regarding your request for a speaker. We would prefer this form be completed six weeks prior to your event to allow us the best opportunity to serve you. A minimum of 20 attendees is typically required. You will receive confirmation regarding the receipt of request within 72 hours. Today's Date* Organization Name*Contact Person Name* First Last Contact Person Title*Contact Person Email* Contact Person Phone*Contact Person Cell PhoneOrganization Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Topic of Discussion*Heart & VascularOrthopedic ServicesOncologyCentegra Physician CareEmergency/TraumaCrisisWellness, Nutrition or FitnessOtherMeeting Time* : HH MM AM PM Meeting Date* Type of Organization:*SchoolGovernmentBusinessNon-ProfitOtherType of Audience:*StudentsBusiness LeadersCompany EmployeesEducatorsOtherAudience Size:*10-2021-5051+OtherMeeting Location* Audio/Visual Capability & Preferences (What will you have available?)* Please provide a description of the available audio-visual equipment. Please also describe if handouts are preferred or powerpoints will do.