Keynote Speaking
Please fill out with event organizers information
Organization/Agency
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Name
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First Name
Last Name
Email
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Confirmation Email
example@example.com
Phone Number
*
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Area Code
Phone Number
Date of Event
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Month
-
Day
Year
If applicable
Talk Focus/Topic
*
Please provide details on the topic you would like Dr. Samra to speak on (see MyWorkplaceHealth.com for speaking topics and descriptions).
Event Details
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Please provide specific details on your event, including: Event Title, Date/Timelines, Audience (number of attendees, demographics) & Budgetary Restrictions.
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