INMED Speakers Bureau Request Form
Speaker Request
Who are You Inviting To Speak?
*
Nicholas Comninellis MD, MPH, DIMPH
Todd Franks
Scott Armistead MD, DIMPH
Timothy Myrick MD
Sean Mark MD, DIMPH
Diane Petrie NP-BC, DINPH, AAHIVS
Not Listed - INMED Faculty
If Not Listed, Who:
*
Requested Topic:
*
Contact Information
Your Name:
*
First Name
Last Name
Your Organization/School:
*
Your Contact Email:
*
example@example.com
Your Contact Phone Number:
Format: (000) 000-0000.
Event Information
Event Name:
*
Date of Event:
*
/
Month
/
Day
Year
Date
Event Theme/Topic:
Event Format
Virtual
In Person
Speaker Session Format:
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Keynote
Presentation/Breakout Session
Workshop/Hands-on Skills
Panel Discussion
Other
Event Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Logistics
Number of Speaking Sessions Requested:
*
Expected Audience Size:
Audience Demographics:
Healthcare Professionals
Healthcare Profession Students
Undergraduate Students
General Public
Mix
Other
Will an Honorarium be Provided?
*
Yes
No
Will Hotel and Travel Expenses be Reimbursed?
*
Yes
No
Please List the Specific Day(s) and Time(s):
Will There be a Exhibit/Resource Table Available?
*
Yes
No
Additional Relevant Information or Requests:
Submit
Should be Empty: