Arkansas Center for Health Improvement

Speaking Requests

Speaking Request Form

Please complete and submit the following form when requesting an ACHI staff member to speak at an event.

* Name of staff requested to speak:

Event Details

* Date/Time of Event:
* Date/Time of Requested Presentation:
* Name of Event:
Theme of Event:
* Location of Event:
Number of Attendees:

* Type of Invitation

If you selected 'Other', please tell us about the type of event:

Topic for Presentation:
Length of the speech/workshop/panel discussion:
If this is a panel discussion, who are the other participants and who is the moderator?
If this is a keynote/plenary, who are the other presenters?
Is there a draft event agenda available?
Do you require a bio, photo, etc?
What A/V equipment will be provided?
Will the following will be compensated?                  

Please provide information regarding the contact person for this event

* Name:
* Office/Cell Phone Number:
Fax Number:
* Email Address:

* Fields marked with an asterisk (*) are required

Arkansas Center for Health Improvement
1401 West Capitol
Suite 300 (Victory Building)
Little Rock, AR 72201