Speakers Bureau Request

Requestor Information

Name *

First

Last *

Last

Title

Official Organization Name (for agreement purposes) *

Phone *

Email *

Address

City

State/Province

Zip/Postal

Alliance Member?

Assembly of State Associations Member?

Event Details

What Type of Event Are You Planning?

Board/strategy meeting

Quality Workshop

Palliative Care Workshop

Regulatory Workshop

State association meeting

Topical conference

OtherOther

Event/Program Name

Event/Program Venue Address

City

State/Province

Zip/Postal

Country

Hotel for Event (if different)

Hotel Address for Event

City

State/Province

Zip/Postal

Country

Event Date (Month Day, Year)

Event Start Time

Event End Time

Alternate Dates (Month Day, Year)

Speaker and Presentation Details

Presentation Content Contact (if different from requester) Name (First/Last):

Email

Requested Speaker(s)

Requested Topic(s)

Please include information about which areas of care at home will be represented in the audience and should be covered in the presentation (home health, hospice, home care, Medicaid HCBS, palliative care). Please also include any specific topic requests for the presentation. We will do our best to fulfill your request, and this information will be used to build the presentation.

Presentation Length

Requested Presentation Format

If other, please explain:

Contract Contact

Signatory Name

Signatory E-mail

Signatory Title

Signatory Phone