FMA President Speaker Request

Office of the President
Please complete this form at least four months prior to the event date. If you have any questions, contact Cortney Jones at cjones@flmedical.org or call 850-224-6496.
What is the name of the organization hosting the event?*
Contact Name*
Email of contact*
example@example.com
Phone number of contact*
Event Start Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Event End Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Event Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of request (Please check all that apply)*

KeynoteInstallationGeneral FMA UpdateLegislative UpdateWelcome/Closing RemarksCME/Other
Please Explain CME/Other in Detail
Time allotted for speaking engagement (excluding Q&A)*
Minutes
Will there be a Speaker Q&A session?

YesNo
Length of Q&A session (in minutes)
Speaking start time

Hour Minutes

AM/PM Option
Expected attendance size*
Please indicate the type of event (e.g. conference, dinner, county medical/specialty society meeting, etc. and a brief summary of the FMA President's responsibilities at the event.*
Distinguished guests present (provide names, titles & organization)
If the President is not available, would you like another FMA Board member to attend?*
Will the organization cover the cost of:*

TravelHotel accommodationsNoneOther
Can the FMA set up a booth?

YesNo
If yes, what time?

Hour Minutes

AM/PM Option
Event Attire:*

Black tieBusinessOther
Should be Empty:

Office of the President