PAMED Speaking Engagement Request Form

PAMED Speaking Engagement Request Form
Thank you for your inquiry regarding speaker requests.

To ensure optimal planning and coordination, we kindly ask that all requests be submitted no less than six weeks in advance of the event. A PAMED staff member will reach out to you within 7 days of your request.
Event/Meeting Basics
Title of Event/Meeting*
Event/Meeting Start Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Event/Meeting End Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Speaker to RSVP By:*

MonthDayYear
Date
Event Location*
If meeting link is not available, please put "Link will be forthcoming"
Link
If meeting link is not available, please put "Link will be forthcoming"
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group/Organization/Hospital Name*
Type of Attendees*

PAMED MembersPAMED Non-membersPhysiciansResidentsStudentsPractice AdministratorsGeneral PublicOther
Special Attendees
Please list any attendees that the speaker should be aware of

Point of Contact
Name*

First NameLast Name
Title*
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Event/Meeting Materials
Are handouts expected/welcomed?*

YesNo
Is use of a PowerPoint appropriate?*

YesNo
What date do you need the slides by?

MonthDayYear
Date
Do you need any materials from PAMED to assist in the event/meeting?

Professional headshotShort BioCVOther
What date do you need the materials by?

MonthDayYear
Date
Should be Empty:

Event/Meeting Basics