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Speakers Bureau Request

Contact Information:

Date of Request

Month

Day

Year

Name of Requestor

Organization Name

Organization Website

Address

City/State/Zip

Phone

Speaker Request Information:

Name of Event

Location (city/state)

Date

Month

Day

Year

Location (hotel, business, center)

Requested Topic

Requested Speaker

Time length (minutes)

Estimated # of attendees

Notification date

Month

Day

Year

Will this program be offered for CE credit?

Yes

Reimbursement:

Travel Expenses

Yes

Comment

Honorarium

Yes

Amount

Promotional Opportunity (program ad, press release, etc. )

Other

Reimbursement is required. An organization that is requesting a CCMC Commissioner to speak without reimbursement must include supporting documentation for consideration by CCMC

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Speakers Bureau Request

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