Speaking Engagement Request Form

If you would like to mail your form instead, download it here: PHS Speaking Engagement Request Form (.pdf, 1 page)

Today’s Date:

Name of Your Organization:

Requested Date and Time for Presentation:

The length of a PHS lecture can be adapted to meet your needs (from 1-2 hours)

First Choice:

Second Choice:

Third Choice:

Topic of Presentation:

Location of Presentation:

Name of Meeting Room:

CME Contact Person:

Phone Number:

Fax Number:

Email Address:

Audience (Primary Specialty in Attendance):

Number of Attendees Expected:

PHS is a non-profit 501(c)3 corporation of the Massachusetts Medical Society and is able to receive charitable contributions. Please consider a contribution to PHS in lieu of an honorarium. Our tax I.D. number is 22-3234975. Contributions (to PHS) are tax deductible to the extent provided by law.

Travel Expense Reimbursement Offered:

Total Contribution:

CME Credit: Each accredited organization can offer CME credit for this program.