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 contact@cmlmd.org.

Email address *
Part 1: Event Organizer
Please tell us about your organization.
Name of Organization Submitting Request *
Your answer
Event Sponsor(s)
Your answer
For Profit/Not for Profit *
Point of Contact Name *
Your answer
Point of Contact Title
Your answer
Point of Contact Email *
Your answer
Point of Contact Phone Number *
Your answer
Part 2: Event Details
Please tell us about the event.
Event Name/Title *
Your answer
Event Location *
Your answer
Event Date *
MM
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DD
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YYYY
Event Time *
Time
:
Event Type (conference, dinner, small group, etc.) *
Event Purpose/Goal *
Your answer
Event Website
Your answer
Part 3: Presentation/Speech Details
Please tell us how and what you would like Chaplain Tarif to speak about.
Requested Topic *
Your answer
Presentation Format *
Expected Duration *
Your answer
Part 4: Additional Information
Deadline for Acceptance *
MM
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DD
/
YYYY
Please list any additional information and/or requests
Your answer
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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