2010 Speakers’ Bureau Application Form

Fill the in the form below or mail it in with the print version. pdf document

Fields marked with an * are required.

Title: (Dr., Ms., Mr/s., etc.)
First:*
Last:*
Street address:*
Street address 2:
City:*
State:*
Zip:*
Mailing address:
(if different than above)
City:
State:
Zip:
Primary contact phone:*  (area) HomeOfficeCell
Alternate phone:  (area) HomeOfficeCell
Fax: (area)
E-mail:
Please provide a brief (one or two paragraph) biography. This will be distributed to requesting organizations for their informational and / or promotional purposes. Include experience, affiliations, publications, etc.*
Please indicate if your presentation requires any special equipment or set-up. For example, podium, table(s), chair(s), microphone/public address system, lighting requirements (a room that can be darkened), an extension cord, a projector, computer, special software, a projection screen, etc. Be aware that the Society does not provide equipment to speakers. Small organizations or organizations that don’t have their own meeting space may not be able to provide special equipment. *
If you require no special equipment simply enter, "None".
One last thing...Please provide a photograph by email or postal service to be used on our web site or for promotional purposes. (Not required but speaker profiles with photos seem to draw more requests.)