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Home Calendar of EventsSpeaker Request Form

If you wish to make a presentation proposal, please complete and submit the following form in its entirety, as only complete forms will be considered. It is our policy to review all completed applications and file them for consideration on appropriate programs. NAMSAP requires speakers to provide information in an educational, non-commercial, and non-self-promotional manner.

Note: * denotes required field

Submitted by:

* Name:
Title:
Company:
NAMSAP Corporate Sponsor:
NAMSAP Professional Member:
NAMSAP Associate Member:
* Phone:	Ext:
* Email:

Presenter:

* Name:
Title:
Company:
* Credentials:
* Address:
* City:	State:
* Zip/Postal Code:
Country:
* Phone:	Ext:
Fax:
* Email:

Co-Presenter	Phone	Fax	E-mail
1.
2.
3.

Speaking Experience
Specify three recent speaking experiences and provide following information for each:

Topic	Date	Location	Contact Name	Contact Number	Contact

* Proposed Presentation Title:

* Length of Presentation:

* Description of Presentation: (100 words or less)

* Type of Presentation: On-site Webinar/Audioconference

Knowledge Level of Presentation:
	Introductory (Assumes the participant has little or no knowledge of the areas covered)
	Intermediate (Ideal for a participant with general knowledge of the literature and professional practice within the areas covered)
	Advanced (Developed for the participant who has a thorough knowledge of the literature and professional practice of the content covered)

Learning Objectives:
(Complete this sentence, “At the completion of the presentation, participants will be able to…”)

Additional Comments: