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Surgeon General Speaking Request Form

Please note that speaking engagements cannot be granted if submitted less than 10 days prior to the event.  If the Surgeon General is not available, a designee may be appointed to speak at your event

Basic Event Information
Name of Event
Name of Organization
Date of Event
Time of Event
Dress
(i.e., formal, business casual, casual)
Event Location
(full address)
Confirmation Date
(i.e., the date by which you must receive a response)
Primary Contact Information
Name
Email
Phone Number
Fax Number
Cellular Number
Mailing Address
Alternate Contact Information
Name
Email
Phone Number
Fax Number
Cellular Number
Mailing Address
Requested Role for the Surgeon General at Your Event
Please describe the speaking role, if any, for the Surgeon General (e.g., keynote speaker, introduction, attendance only)
Requested length of time for remarks
(Please note: Most speaking requests granted are not longer than 10 minutes)
If the Surgeon General will be speaking, please provide requested topic.
If the Surgeon General will be speaking, who will introduce him?
Please describe the type of audience and number of people attending this event.
Does DOH have any programs relating to this entity?



Additional Information and Notes
Please provide additional information if needed