Contact Information: Date of Request Name of Requestor Organization Name Organization Website Address City/State/Zip Phone Email Speaker Request Information: Name of Event Location (city/state) Date Location (hotel, business, center) Requested Topic Requested Speaker Time length (minutes) Estimated # of attendees Notification date Will this program be offered for CE credit? Yes No Reimbursement: Travel Expenses Yes No Comment Honorarium Yes No Amount Promotional Opportunity (program ad, press release, etc. ) Other Reimbursement Reimbursement is required. An organization that is requesting a CCMC Commissioner to speak without reimbursement must include supporting documentation for consideration by CCMC Submit
