Rare Disease Innovation & Partnering Summit Speaker Inquiry Form

Question Title

* 1. Potential Speaker Information

Full Name

Title

Company/Affiliation

Email

Phone Number

Question Title

* 2. Additional/Preferred Contact Information (If applying on behalf of another individual)

Full Name

Title

Company/Affiliation

Email

Phone Number

Question Title

* 3. Please provide a brief summary of the proposed topic or case study.

Question Title

* 4. Please select the preferred format of your talk.

Short talk (15-20 minutes)

Standard talk (30-45 minutes)

Workshop (90+ minutes)

Panel Discussion (3-4 panelists + moderator; 45-60 minutes)

Other (please specify)

Question Title

* 5. Please share any additional information that you think would be relevant for the Conference Team to consider.

Question Title

* 6. If you would like, you may attach a brief bio for the speaker or additional information about your organization here.

DOCX, DOC, JPEG, JPG, PDF, PNG file types only.