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 Meeting/Conference/Event
Event start date

MonthDayYear
Event end date

MonthDayYear
Type of event
Venue
City/State
Virtual Presentation Type
Event sponsor(s)
Information about your organization

Other
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?
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?
Is the time slot flexible and/or tentative?
If yes, please provide additional information below
Format of talk
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
Should slides be used in the presentation?
Will press be invited?
If virtual, ADA Compliant?
Will the session be recorded and/or Livestreamed?
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: denise.graddy@ama-assn.org.
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