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1. Would you be willing to be listed on the CMSA website on our Speaker Directory for CMSA Chapter Leaders? (Required.)

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2. Which topic(s) do you speaker on?

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3. Which platform is your preferred method? 

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4. If you are willing to travel, which regions are you able to travel to?

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5. Do you require a honorarium?

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6. If yes, what is your rate? 

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7. Have you spoken with CMSA before? 

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8. If so, which Chapter(s)?

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9. Contact Information

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10. How would you prefer Chapter Leaders to contact you? 

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11. Contact Photo

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