CML MD Speaker Request Form
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

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Email *
Part 1: Event Organizer
Please tell us about your organization.
Name of Organization Submitting Request *
Event Sponsor(s)
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 *
Event Time *
Event Type (conference, dinner, small group, etc.) *
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 *
Expected Duration *
Part 4: Additional Information
Deadline for Acceptance *
Please list any additional information and/or requests
A copy of your responses will be emailed to the address you provided.
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