(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 CodePhone Number
Who is your Field Student Recruitment Manager?
Event Name
Event Details
Event Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearSpeaker requests must be made at least 30-days in advance.
Event Start Time

:HourMinutesAM/PM Option
Event End Time

:HourMinutesAM/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?
If in-person, what is the venue address? If virtual, please leave blank.

Street Address

Building Name/ Venue Name (if applicable)

CityState

Zip Code
Event Audience (Please select all that apply)

Other
Expected Number of Attendees
Did the AMA award Grant funding for this event?
Is the State Society planning to participate?
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?

Other
Desired Speaker

First NameLast Name
Speaker's email
Not required, but encouraged
Is there anything else you'd like to share?
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(MSOP) Guest Speaker Request

Do you have a specific topic or speaker in mind?