SHIBA speaker request form

To request a speaker, fill out this form and select the Submit button.

Your contact information
Organization:
Contact name:
Phone:
Fax:
Email:
Presentation type Select one of the following speaker presentations:
Information about SHIBA How to get ready for Medicare Information about Medicare Part D Preventive care benefits Health care coverage for kids Understanding your health care coverage options How to fight health care fraud and abuse Long-term care overview
Event information
Name of event:
Date:	(mo/day/yr)
Location:	(city)
County:	(county)
Length of event:	(hrs, mins)
Panel discussion:	(yes/no)
# of attendees:	(approximate)
Equipment needs
Overhead projector:	(yes/no)
Projector:	(yes/no)
Screen:	(yes/no)
Microphone:	(yes/no)
Podium:	(yes/no)
Other equipment:
Comments:

Updated 04/22/2013

Need more help?