Chapter Event Request Form

Event/Webinar Title*
Event/Webinar Description*
Event Agenda (provide if available, can be tentative)
At what educational level will this event be targeted? (if applicable)
For what type of RQAP re-registration units do you believe this event or webinar should qualify?*
Presenter Name(s)*
Speaker 1 brief biosketch (2-3 sentences)
Additional Speakers brief biosketches (2-3 sentences each) (if there are additional speakers)
Moderator Name (for webinar or virtual event)
Your chapter's members at one fee, and any non-members at a different feeYour chapter's members, SQA members, and other chapter's members for free, and any non-members for an extra feeYour chapter's members only for free, and any non-members for an extra feeAll members and non-members for free
Registration Fee for Members*
Registration Fee for Nonmembers*

Estimated/Preferred Event/Webinar Date(s)
1st Alternate Date(s)
2nd Alternate Date(s)
Preferred Event Start Time:
Preferred Event End Time:
Registration Deadline Date:
Event Address (for in-person events)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Event Announcement Distribution
Your Chapter MembersSQA MembersAll Contacts in your Chapter RegionAll Other Chapter MembersAll NonmembersAll of the Above
Additional Comments (optional)
Please add any additional relevant information for your event.
Should be Empty:

Event Announcement Distribution