Speaker request form

Name of event(Required)

Date & time of event(Required)

Purpose/objectives of event(Required)

Topic(s) you'd like the speaker to touch on(Required)

Geographic location of event

How will the event be held?(Required)

If other, please specify

Approximate number of participants

Description of audience (who will be attending, what are their areas of expertise?)

Preferred speaker(s)

Total time allotted for the presentation (including Q&A), in minutes(Required)

Name(Required)

First Last

Email(Required)

Organization

Phone number

Additional information

Canadian Health Adaptations, Innovations, & Mobilization (CHAIM) Centre

Carleton University
1125 Colonel By Drive
Ottawa, Ontario
613-520-2600 ext. 7825