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
Format: (000) 000-0000.
Event Start Date & Time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Event End Date & Time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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)
Please Explain CME/Other in Detail
Time allotted for speaking engagement (excluding Q&A)
Minutes
Will there be a Speaker Q&A session?
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:

Other
Can the FMA set up a booth?
If yes, what time?

Hour Minutes

AM/PM Option
Event Attire:

Other
Should be Empty:

Office of the President