(MSOP) Guest Speaker Request

(MSOP) Guest Speaker Request

Speaker requests must be made at least 30-days in advance. Once your request is received, please allow our team 10 business days to process your request.
First Name *
Last Name *
School Email Address *
example@example.com
Medical School Name *
Phone Number *

Area Code Phone Number
Who is your Field Student Recruitment Manager? *
Event Name *
Event Details *
Event Date *

Month Day Year
Speaker requests must be made at least 30-days in advance.
Event Start Time *

: Hour Minutes AM/PM Option
Event End Time *

: Hour Minutes AM/PM Option
Please provide a brief agenda for your event. How long will the speaker have to present?
e.g. "7pm-8pm: Cocktail hour, 8pm-8:30pm: Introductions, 8:30pm-9pm: Guest speaker"
Is this event virtual or in-person? *

Virtual In-Person Hybrid
If in-person, what is the venue address? If virtual, please leave blank.

Street Address

Building Name/ Venue Name (if applicable)

City State

Zip Code
Event Audience (Please select all that apply) *

M1 M2 M3 M4
Expected Number of Attendees *
Did the AMA award Grant funding for this event? *

Yes No
Is the State Society planning to participate? *

Yes No Not Sure Yet
Do you have a specific topic or speaker in mind?

Please select one of the following. If you're not sure- choose a topic and we will help source a list of suggested experts for you.
What type of subject matter expert are you looking to have speak?

Advocacy & Policy Health Equity AMA Leadership Future of Medicine
Desired Speaker

First Name Last Name
Speaker's email
Not required, but encouraged
Is there anything else you'd like to share?
Should be Empty:

(MSOP) Guest Speaker Request

Do you have a specific topic or speaker in mind?