CML MD Speaker Request Form

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Thank you for your interest in having Chaplain Tarif Shraim at your event. In order to help us facilitate your request, please complete and submit the following form (and any corresponding attachments) at least 2 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 contact us at contact@cmlmd.org.

Email *

Part 1: Event Organizer

Please tell us about your organization.

Name of Organization Submitting Request *

Event Sponsor(s)

For Profit/Not for Profit *

For Profit

Not for Profit

Point of Contact Name *

Point of Contact Title

Point of Contact Email *

Point of Contact Phone Number *

Part 2: Event Details

Please tell us about the event.

Event Name/Title *

Event Location *

Event Date *

YYYY

Event Time *

Time

Event Type (conference, dinner, small group, etc.) *

Conference

Dinner

Small Group

Other:

Event Purpose/Goal *

Event Website

Part 3: Presentation/Speech Details

Please tell us how and what you would like Chaplain Tarif to speak about.

Requested Topic *

Presentation Format *

Keynote Address

Roundtable

Panel

Other:

Expected Duration *

Part 4: Additional Information

Deadline for Acceptance *

YYYY

Please list any additional information and/or requests

A copy of your responses will be emailed to the address you provided.

Submit

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