Contact Information: Date of Request Name of Requestor Organization Name Organization Website Address City/State/Zip Phone Email Speaker Request Information: Name of Event Event Format In-Person Virtual Location (city/state) Date Location (hotel, business, center) Requested Topic Requested Speaker Time Length (minutes) Estimated # of Attendees Notification date Will this program be offered for CE credit? Yes No Reimbursement: Travel Expenses Yes No Comment Honorarium Yes No Amount Promotional Opportunity (program ad, press release, etc. ) Other Reimbursement Reimbursement is required. An organization requesting a CCMC Commissioner or staff to speak without reimbursement must include supporting documentation for consideration by CCMC. Reimbursement supporting documentation Upload Upload requirementsOne file only.128 MB limit.Allowed types: pdf, doc, docx. Submit
