CHERNspeaker Request Form
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Thank you for your interest in CHERNspeak! Please use this form to request speakers. You may request up to 3 topics from each speaker. Please fill out a separate form for each speaker of interest.

After you submit this form, your request will be sent to the requested speaker and you will be contacted by the CHERN administration regarding the status of your request. Thank you.

YOUR (REQUESTOR) INFORMATION

YOUR (REQUESTOR) INFORMATION Hospital name
Hospital Address
Requestor name
Requestor e-mail
Requestor phone number
Lecture setting (CME required)

Please designate the honorarium you plan to offer this speaker.

Please designate the honorarium you plan to offer this speaker. $750 plus expenses (recommended for travel >100 miles)

$500 plus expenses (recommended for travel <100 miles)

Other (please specify)

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SPEAKER INFORMATION

	Please select speaker
Please select the speaker you would like to request:	SPEAKER INFORMATION Please select the speaker you would like to request: Please select speaker

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Topic #1 you are requesting

Topic #1 you are requesting Name of lecture
Preferred date & time
Alternate date #1
Alternate date #2
Questions/Concerns

Topic #2 you are requesting

Topic #2 you are requesting Name of lecture
Preferred date & time
Alternate date #1
Alternate date #2
Questions/Concerns

Topic #3 you are requesting

Topic #3 you are requesting Name of lecture
Preferred date & time
Alternate date #1
Alternate date #2
Questions/Concerns

CHERNspeaker Request FormExit this form