Massachusetts Medical Society: Speaking Engagement Request Form

    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.

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