American College of Physicians Speakers Panel -
The following survey is to request a speaker for your upcoming event.
Thank you for your interest!

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* 1. Requesting Institution/Organization

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* 2. Contact Person

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* 3. Title

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* 4. Email

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* 5. Phone Number

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* 6. Event Type

Other (please specify)

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* 7. Event Time

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* 8. Event Length

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* 9. Please provide the topic(s) you are requesting for your speaking engagement

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* 10. Please list the requested speaker or we will provide based on the topic requested

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* 11. Our institution will pay a donation to ACP Illinois Chapter

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* 12. Donation amount (this is donated to ACP Illinois Northern Chapter to support the ACP Speakers Panel)