PAGE Speakers Bureau Reimbursement Form
Name of Affiliate *
If your Affiliate is not listed, please contact the PAGE Executive Secretary to confirm that Affiliate dues have been paid.
Person completing this form *
Your answer
Name of Speaker *
If a speaker's name is not on the list they are no longer a speaker for PAGE.
Name of Presentation *
Your answer
Date of Presentation *
MM
/
DD
/
YYYY
Please rate the Presenter *
Excellent
Very Good
Good
Poor
Ease of scheduling speaker
Communication prior to presentation
Effectiveness of Presention
Presentation topic and contenct was as described
Likelihood of inviting this speaker back
Overall rating
How did you learn about this speaker? *
Your answer
Additional comments about the presentation/ presenter
Your answer
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