(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
Speaker 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?*

VirtualIn-PersonHybrid
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)*

M1M2M3M4Other
Expected Number of Attendees *
Did the AMA award Grant funding for this event?*

YesNo
Is the State Society planning to participate?*

YesNoNot 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 & PolicyHealth EquityAMA LeadershipFuture of MedicineOther
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?