CPSO Speaker Request Form Please fill out the information below to request a CPSO representative to speak at your event. Question Title * 1. Your Contact Information Full Name E-mail Phone number Question Title * 2. Your Organization Name of Group or Organization Website Address Question Title * 3. Your Event Date(s) of event Audience type (physicians, medical students, residents, staff, patients, public, etc.) Approx. audience size Question Title * 4. Presentation Style Q&A and Discussion Interactive/Engaging Workshop/Activity-Based Lecture/Talk Other (please specify) Question Title * 5. Topic(s) of Interest (e.g. CPSO policies, CPSO programs, general updates, etc.) Question Title * 6. Is there a sponsorship fee associated with this speaking engagement? No Yes If Yes, please provide more details Question Title * 7. Would you require any materials from us? (e.g. headshot and/or biography of speaker, CPSO logo and branding) Question Title * 8. What is the deadline for booking this speaking engagement? Question Title * 9. Please provide any other details or information. If you have any questions or concerns, please do not hesitate to contact us at CPSOOutreach@cpso.on.ca. Done