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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.

Please complete the form below with as much detail as possible.

Presentation Information


Type of Organization

If other, please describe in the notes section

Topic of Presentation

If other, please describe in the notes section

Audience and Key Participants

If other, please describe in the notes section


Travel Expenses Covered:

Host Organization Contact Information

Name and Brief Description of Host Organization:
(input limit 500 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:

Host Contact Country:


Email Address:   Daytime Phone:


Expected Media Coverage:

Logistical Information


Event Title: (input limit 150 characters)

Event Date and Time:
PM
AM

Date:

Pick a date
Objective of Event/Conference:
(input limit 500 characters)


(If Event Location is the 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:

Event Country:

Type of Presentation:
Length of Requested Presentation:

Audiovisual Capabilities:

Special Notes/Instructions:
(input limit 500 characters)

Agenda

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


 

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