Speakers Bureau Request Form Please complete the following information and e-mail it to the UCMG Speakers Bureau or print this form and fax it to (323) 361-8490

Organization
Contact Person
Phone:
Fax
Please include area code and country code (if necessary)
Address
City
State/Province
Zip/Postal Code
E-mail
Presentation Information:
Date and Time
Alternate Date and Time
Topic
Requested Speaker
Audience (size and composition)
Location
Honorarium
Additional comments

E-mail your completed form to:		Pdinsmore@chla.usc.edu
Or print this form and return it to:		UCMG Speakers Bureau 6430 Sunset Blvd., Suite 600 Los Angeles, CA 90028-7900 Fax: (323) 361-8490
Or call:		1-800-3-KID-CME (1-800-354-3263) or (323) 361-2752