Request a Speaker

Your Information

Name *

Professional Title *

Organization *

Email *

Phone Number *

Business Address

Street Address

Address Line 2

City

State

ZIP code

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Event Overview

Sponsorship Organization

Name of Event

Event Start Date *

Month

Day

Year

Event End Date *

Month

Day

Year

Event Start Time *

Hour

Minute

Event End Time

Hour

Minute

Event Description *

Event Location

Additional Event Information

Estimated Number of Attendees

List of press/media in attendance

Will there be other speakers?

Yes

List speakers

(one per line)

Important Information

Event materials (program, guest list, copy of brochure or invitation, etc.) must be submitted to nexusipe@umn.edu at least seven days prior to the event. Additional materials may be requested as needed. Please notify us at nexusipe@umn.edu immediately regarding cancellation or any changes to the event as well as delays in providing event materials. Requestors are not authorized to use the National Center for Interprofessional Practice and Education name or logo for promotional purposes until a confirmation of attendance has been sent by National Center staff. Thank you.

Agreement *

I have read and understand the Important Information section of this form.

Once event participation is confirmed, I authorize the National Center to publicize my event on the National Center's event calendar.

Agreement 2 *

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