Speakers and Consultants Bureau: Speaker Request Form

Please complete all of the fields below. If a question does not apply to your organization and/or the event for which you are requesting a speaker, place an “N/A” in the field.

* denotes a required field

Name of MI-ACE Member Institution *

Requesting Organization *

Event Date & Time *

Event Location (full address) *

Presentation Topic *

Amount of time for speaker *

Technology Requirements *

Additional Information about Event (demographics, number of attendees, etc.) *

Contact Person Name *

Contact Person Phone *

Contact Person Email *

Page last modified May 1, 2020

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