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Speaker Request Form

Please complete the form below with as much detail as possible. Requests can take up to 30-45 days to process. Allow enough time to seek alternative arrangements if CDC is unable to identify a speaker. You may contact the Speakers Bureau at speakersbureau@cdc.gov or 404-639-7796.

Presentation Information

Type of Organization


If Type of Organization "Other", please list:


Topic of Presentation


If Topic of Presentation "Other", please list:




Audience and Key Participants

   

Type:


Host Organization Contact Information

Name and Brief Description of Host Organization:
(input limit 800 characters)

Host Organization Web Address:
(input limit 300 characters)

Host Contact Name:

Host Contact Street Address 1:

Host Contact Street Address 2:

Host Contact City, State/Territory, Zip/Postal Code:
State/Territory: Zip:

Host Contact Country:

Email Address:

Daytime Phone:

Cell Phone for Onsite Contact:


Expected Media Coverage:




Logistical Information

Event Title:
(input limit 150 characters)
Event Date and Time:
Date:   (MM/DD/YYYY) AM  
Objective of Event/Conference:
(input limit 800 characters)

(If Event Location same as Host Location, leave blank and skip to Length of Requested Presentation)

Event Location (building name):
(input limit 150 characters)

Event Street Address 1:

Event Street Address 2:

Event City, State/Territory, Zip/Postal Code:
 State/Territory:  Zip:

Event Country:

Length of Requested Presentation:



Type of Presentation:



Plenary

Audiovisual Capabilities:
    

Type:





Special Notes/Instructions:
(input limit 800 characters)

Agenda

Please copy and paste agenda into space below:
(input limit 3700 characters)
 

Page last modified: April 30, 2009