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Dosher Memorial Hospital

Speakers Bureau Request

Thank you for your interest in the Dosher Memorial Hospital Speakers Bureau.
Please fill out this form completely to request a speaker from the Dosher Hospital Speakers Bureau. Requests for speakers should be made a minimum of 30 days prior to your meeting to provide us ample time to match a speaker with your request.
* Organization
Enter the name of your organization.
* Name
Enter your name.
* Address
Enter your address.
* City
Enter your City.
* State
Enter your state.
* Zip
Enter your Zip Code.
* Phone
Enter your Phone Number
* Email
Enter your Email Address.
* Meeting Date
Enter the Date of the meeting for which you are requesting a speaker.
* Meeting Time
Enter the time of your meeting.
* AM or PM AM     PM    
* Topic of Presentation
Enter the topic which is your first topic for the presentation.
* Second Choice Topic
Enter your second choice for a presentation topic (in case we cannot accommodate your first choice).
* Number of Attendees
Please enter the number of people you anticipate will be in attendance at your meeting.
* Contact Preference
Please enter the best method of contacting you (phone or email) to discuss your request. If by phone, also provide the best time to call you.
  Additional Notes
Please add any additional information you wish regarding your request for a speaker.