Speaker's Bureau Request Form

* required information

Speaker's Bureau Request Form
Your Information
Company Name:
First Name:*
Last Name:*
Email:*
Phone:
Fax:
Address Line 1:*
Address Line 2:
City:*
State:
Province:
ZIP/Postal Code:*
Country:

Presentation Information
Date and Time:
Alternate Date and Time:
Topic:
Requested Speaker:
Audience (size and composition):
Location:
Honorarium:
Additional Comments:

If you have trouble submitting this form, you can E-mail the information asked on this form to: Pdinsmore@chla.usc.edu

Or print this form and return it to:
UCMG Speakers Bureau
6430 Sunset Blvd., Suite 600
Los Angeles, CA 90028-7900
Fax: (323) 361-8490

Or call:
1-800-3-KID-CME
(1-800-354-3263)
or (323) 361-2752