Thank you for your interest in the Chicago AHEC Speakers Bureau. Please complete this short survey to help us get to know you and effectively match you with speaking opportunities. Chicago AHEC staff will review your application and follow-up with next steps for you and Speakers Bureau activities. Questions? Email us at chicagoahec@hmprg.org. Thank you.

1. First and Last Name:

2. E-mail:

3. Profession:

4. Regarding your profession, are you currently:

5. Title, Degrees (if applicable)

6. Are you affiliated with any organization, community group, college/university, or company?