Speaking Request Form — Health Justice MD

Name of Speaking Event*

Name of contact person*

First Name

Last Name

Phone Number

(###)

###

####

Speaking Event Specifics

Event Location*

Is event date fixed or tentative?*

Event Date

Event Time*

Duration of Speaking Time

Are there other speakers? If so, who?*

Number of attendees expected*

Honorarium (please write a specific U.S. dollar amount)*

The honorarium check should be made out to Health Justice MD

Will honorarium be given in advance?*

Yes

Would you like to advance purchase a copy of Undue Burden for each attendee?

Special arrangements needed