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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 Start Time: *Event Time Zone *Is speaking start time flexible?:
*Speaking Duration:
*Q&A Duration:
*Address Type:

*Proposed Speaking Topic(s):

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

Event Address *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 Contact *Event 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?

Content created by Office of the Surgeon General
Content last reviewed on December 16, 2020

Surgeon General Invitation Request Form

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