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Speaker Request

Interested in having a member of the NHSA team speak at your event? Please complete and submit the form below at least four weeks before the event and someone from NHSA will reach out!

Event Primary Contact

First Name

Last Name

Organization Name

Email

Office Phone

Mobile Phone

Is the Primary Contact the same as the "Day of the Event" Contact?

YesNo

Day of Event Contact

First Name

Last Name

Email

Mobile Phone

Event Details

Host Organization

Type of Organization

If other, please provide details below

Name of Event (please include a brief description)

Event Start Date

Event End Date

Expected number of attendees

Venue Name

Venue Address

Venue City

Venue State

Venue Zip Code

Overall Topic(s) for discussion/presentation

Speaker Request

NHSA offers a range of engaging speakers based on the needs of your audience and event. Please let us know:

What is the subject matter of this session?

What outcome do you expect?

Speaking and Meeting Requests

Date of Speaking Engagement

Room #

Time Slot of Speaking Engagement

Speaker's Role for Speaking Engagement

Requested length of time for the speaking engagement

Type of Event

Description

If a PowerPoint will be used during a presentation, is it acceptable for the presentation to be provided via flash drive?

YesNo

If a PowerPoint will be used during a presentation, will a projector and a computer be provided for the speaker?

YesNo

Additional Information

Please upload the Program Booklet for the Event

Please upload the "Schedule at a Glance"

Information needed from NHSA (please check all that apply)

Speaker BioFlight Itinerary Photo of the Speaker

Additional Information and Requests

Logistical Information for Speaker

Please list 1-3 major airports near the hotel where the speaker will be staying

Is there an existing hotel reservation for the requested speaker ?

YesNo

Will a reservation be made for the requested speaker?

Please provide the hotel confirmation number:

Hotel where the speaker will be staying

Hotel Address

Hotel City

Hotel State

Hotel Zip Code

Does the hotel have shuttle service to and from the airport?

YesNo

If yes, please provide the contact information for the Hotel Shuttle

If no, will ground will ground transportation be provided from the airport to the hotel?

Private DriverTaxiOther

Please provide a point of contact for the method of ground transportation that you have chosen.

Hotel is the same as the venue location listed above

YesNo

How will the Speaker be transported to the event?

Costs Incurred by Speaker

Will all travel and lodging costs for NHSA staff be covered by the requester?

YesNo

ACKNOWLEDGEMENT

By clicking yes, the requester is in agreement to pay for all of the speaker's costs including travel, meals, and any other possible expenses. Please sign your name below.

First Name

MI

Last Name

Job Title

Please include who should receive invoicing (usually 30-60 days, post event)

Name of Organization

First Name

Last Name

Job Title

Email

Phone

Thank you for requesting a member of the NHSA staff to participate in your event.Your request will be reviewed by NHSA staff and you will receive a response within 5 business days.

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