Speaker's Bureau Request - Cobb & Douglas Public Health

Request a Speaker

To request a speaker, please fill out this form. All requests are handled on a first-come, first-served basis. Not all requests can be accommodated due to general obligations and availability.

To review a list of our most popular topics, please click here.

Name*

First Last

Phone*

Other Phone

Email*

About Your Organization

Organization Name*

Tell us a little about your organization

How Many Members Belong?

About Your Request

Who is your desired speaker?*

District Health Director/Deputy Director
District Health Director/Deputy Director is preferred, but another subject matter expert is acceptable
I’ll let Cobb & Douglas Public Health determine who’s best for my event and audience

Event Title*

Event Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Event Date*

Event Time*

: HH

MM

How Many People are Expected in the Audience?*

Describe the audience (examples: business owners, physicians, mostly parents, high school students, etc.)*

Event Attire*

Length of Desired Speech or Address*

Desired Topic (Describe the nature of the speech and what the audience intends to hear.)*

Is PowerPoint or projection equipment available at the location?*

Yes, They're Available
Yes, They're Available But Not Necessary
No, They're Not Available

Use this space to add any additional notes on arrival, accommodations, special requests, etc.

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Request a Speaker

About Your Organization

About Your Request

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