HLCOM Speaker Request | State of Michigan

Thank you for your interest in having an HLCOM speaker at your event. Our Executive Director and Commissioners are experts in a variety of topic areas. In order to help us facilitate your request, please complete and submit the following form at least 3 weeks prior to the event, and allow 3-5 business days for decisions to be made. If you have any questions or need help completing the Speaker Request Form, please email: [email protected]

*At this time HLCOM prefers a virtual speaking engagement to reduce the spread of COIVD-19. Should a virtual engagement be impossible, please explain below and we will take this into consideration.

*Name of Organization Submitting Request

*Event Sponsor(s)

*Is your organization for Profit or Non-Profit? Profit Non-Profit

*Coordinator/Point of Contact Name

*Coordinator/Point of Contact Title

*Coordinator/Point of Contact Phone Number

*Coordinator/Point of Contact Email Address

Event Details

*Event Name/Title

*Event Location

*Event Date

*Event Time

*Is this event virtual or in-person? Virtual In-Person

*Event Type Conference Dinner Small Group

*Event Purpose/Goal

*Event Website

Presentation/Speech Details

*Requested Topic

*Presentation Format Keynote Address Roundtable Panel Discussion

*Expected Duration

*Will the speech be followed by a Q&A session? Yes No

Audience Details

*Audience (Approximate size of the audience. Also briefly describe its make-up and if membership is required to attend.)

*Honorable Guests (List names and titles of members of Congress, CEOs, or other VIPs participating in, or attending the event.)

*Media (Will media be invited? If so, will the event be open or closed press? Also, describe and submit a media list.)

Additional Information

*Deadline for Acceptance

*Cost of Attendance (Please include member and non¬member price, if applicable)

*Offer of Payment/Reimbursement (Payment may only be accepted as a donation to “HLCOM Scholarship Fund”, dining, lodging, travel, etc.)

*Will the event sponsor need the speaker to sign a disclaimer/release form? Yes No

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Speaker Request

Event Details

Presentation/Speech Details

Audience Details

Additional Information