AMA Board of Trustees Speaker Request Form

AMA Board of Trustees Speaker Request Form

Please complete and submit the form below to request an AMA trustee to speak at your upcoming event. To help us make the most informed decision about your request, please complete the following questionnaire. We will be in touch with you shortly.
Section 1: Contact Information
Name of Company/Organization*
Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Organization or event website URL*
Section 2: About the Conference
Event start date*

MonthDayYear
Event end date*

MonthDayYear
Type of event*

In-PersonRemote/VirtualHybrid
Venue*
City/State*
Virtual Presentation Type*

LivePre-RecordedPre-Recorded with Live Q&A
Event sponsor(s)*
Information about your organization*

For ProfitNot for ProfitMembershipMediaOther
Conference agenda*
If there is a website with your agenda enter the URL; otherwise, paste your full agenda here
Event Description*
Section 3: About the Opportunity/Speaker Request
Requested AMA Trustee*
If the requested trustee is not available, would you accept an alternate speaker?*

YesNo
If yes, please enter your alternate choice, or "open"*
Date of speech*

MonthDayYear
Time allotted for remarks*
Start and end time of presentation*
Is a period of Q&A included?*

YesNo
Is the time slot flexible and/or tentative?*

YesNo
If yes, please provide additional information below*
Format of talk*

KeynotePanel (see below)Fireside ChatPlenary SpeakerOther (see below)
If a panel presentation, please list the other panelists; if other, please describe format*
Topic of keynote, presentation, panel or fireside chat*
Expected audience size*
Audience composition*
Will a slide presentation be required?*

YesNo
Will press be invited?*

YesNo
If virtual, ADA Compliant?*

YesNo
Will the session be recorded and/or Livestreamed?*

RecordedLivestreamed
Recording/livestream details (if any)*
What expenses will be covered for the speaker?*
Are there opportunities for other meetings/appearances in addition to the primary speech (e.g., board, local officials, students, etc.)?*
Please provide any additional information you would like to be considered as we evaluate this request*
Terms and Conditions
You will receive an acknowledgment of your request within 24-48 business hours after receipt of your completed form.

By submitting this form, you certify that the information provided is complete and accurate to the best of your knowledge. You understand that a representative from the AMA Board Representation Office will contact you to discuss the approval/confirmation process, as well as arrangements and costs involved prior to final commitments. You also understand that operational commitments/organizational priorities may take priority and can preclude a scheduled appearance at an approved activity; in such an instance, a replacement will be offered

Upon prior approval of use, in a case where you plan to use the trustee's image and/or AMA logo, you must submit a request and proofs of materials to this office for approval, prior to final printing.

If you have any questions, please send an email to: BOTWebsiteInvitations@ama-assn.org.
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