Surgeon General Invitation Request Form

Speaker Requested: *Would you be willing to accept a surrogate speaker if the one you have requested is unable to participate? *Name of Inviting Organization / Individual: *Organization Description: *Organization Website:Event Name: *Type of Event: *Event Start: *Event End: *Event Description: *Speaking Date: *Speaking Date Flexible: *Speaking Start Time: *Event Time Zone *Is speaking start time flexible?: *Speaking Duration: *Q&A Duration: *Address Type: *Proposed Speaking Topic(s): *

Select all that apply. You may select multiple values by holding down your Ctrl key while selecting.

Speaking Topic Details:Event Venue: *If the event is virtual, enter “n/a” for event location fields.

Event Address: *Event City: *Event State: *Event Zip Code: *Event Country: *

Are you expecting any distinguished guests at this event? *Are any other HHS officials speaking at this event? *Please provide the names of any registered lobbyists who will be in attendance: *What types of media are invited to the event? *Audience Size: *Audience Composition & Proportions: *

Event ContactEvent Contact Name: *Event Contact Title: *Event Contact Email: *Event Contact Phone: *

Is the inviting organization registered as a lobbyist? *Is the inviting organization a 501(3)(c)?: *Is there a fundraising component to this event? *

Surgeon General Invitation Request Form

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