Speakers Bureau Request

Name *

First

Last *

Last

Title

Official Organization Name (for agreement purposes) *

Phone *

Email *

Address

City

State

Zip Code

Signatory Name

Signatory E-mail

Signatory Title

Alliance Member?

Council of States Member?

Event/Program Name

Event/Program Location

Event/Program City

Event/Program State

Event date

Alternate date(s)

What type of event are you planning?

What type of service do you need?

Topic/Content Requested:

What is the exact time of the speaking engagement? (please include time zone)

Duration of Presentation(s)

Are you interested in offering continuing education credits through Alliance’s Joint Providership for your educational event?

Alliance may jointly provide nursing continuing professional development (NCPD) for nurses and/or continuing medical education (CME) for physicians. Joint Providership credits are charged on a sliding scale.

Yes - Continuing education credit for nurses and/or physicians

No

What is the format of your event?

How would you like the Alliance speaker to attend your event, in-person or virtually?

Preferred speaker(s)

Expected Attendance

Any Other Requests or Useful Information?

Speakers Bureau Request

Speakers Bureau Request Form