Speaker Request Form

Occasionally, IAHCSMM is able to provide a speaker to Chapter or non-profit association events. Those speakers (Elected Board Members or members of the IAHCSMM staff) provide information on a variety of CS and IAHCSMM-related topics. Requests for a speaker should be made at least 6 months in advance and should be submitted using the IAHCSMM Speaker Request Form below.

This form must be submitted to the IAHCSMM Headquarters in order to process your request. Notification on the status of request will be advised via email within three weeks of receipt of completed form.

Chapter Name:*

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Requested Topic:*

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Contact Name:*

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Contact Email:*

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Contact Telephone 555-555-5555:

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Date(s) of Event (mm/dd/yyyy):*

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Location of Event:*

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Time of Requested Presentation:*

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Length of Presentation (Presentations are 1.25 hours in length.)
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What is your Target Audience (check all that may apply):*

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Briefly describe how this program supports IAHCSMM's Mission:*

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Expected Number of Attendees:*

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Submitted By:*

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Will your Chapter sponsor this speaker?*

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*

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Are you seeking sponsorship for this speaker?*

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Has your group requested a speaker from IAHCSMM in the past 2 years?*

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International Association of
Healthcare Central Service Materiel 
Management (IAHCSMM)

55 West Wacker Drive
Suite 501
Chicago, IL 60601
 
Contact Us
Toll Free: 800.962.8274
Direct: 312.440.0078
Fax: 312.440.9474
Email: mailbox@iahcsmm.org