Speakers Bureau Request Form

To schedule a cancer speaker for your group, submit the form below at least one month before the presentation date. Please note that there is a minimum of 25 attendees, and we may request pre-registration to ensure that this minimum is met.

If you have any questions, please contact NYUCI Community Outreach and Education at 212-263-2266 or NYUCIcommunityporgrams@nyumc.org [1].

Contact Information

Name of Organization: *

Mailing Address 1: *

Mailing Address 2:

City: *

State: *

Zip: *

Your Name: *

Title / Position: *

Telephone: *

Email: *

Event Details

Topic of Presentation Requested: *

Date: *

Time: *

Location of Presentation: : *

Address 1: *

Address 2:

City: *

State: *

Zip: *

A/V Available: *

LCD projector and screen

Laptop

Other*

None

(*If other, please specify below.)

Other A/V:

Presentation Description: *

Audience Demographic: *

What size audience do you expect for this program?: *

Please note that there is a minimum of 25 attendees, and we may request pre-registration to ensure that this minimum is met.

How did you hear about NYU Cancer Institute’s Speakers Bureau?: