Speaker Contact Form

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Speaker Contact Form

Speaker Contact Form

If you wish to make a presentation proposal, please complete and submit the following form in its entirety, as only complete forms will be considered. It is the Maine Hospital Association's policy to review all completed applications and file them for consideration on appropriate programs.

MHA requires speakers to provide information in an educational, non-commercial, non-self-promotional manner.

Name of person submitting form: :

Title: :

Company:

Email :

U.S. phone number:

( ) - Second three digits Last four digits

We are an: :

MHA Member Hospital
MHA Corporate Affiliate
MHS Endorsed-Company
None of the above

Presenter Name:

Company:

Title:

Credentials :

Address:

Address 2:

City:

State:

U.S. ZIP code:

U.S. phone number:

( ) - Second three digits Last four digits

Email:

Proposed Presentation Title:

Target audience (Check all that apply):

Chief Executive Officers
Chief Financial Officers
Chief Medical Officers
Chief Nursing Officers
Hospital Trustees
Director/Department Heads
Administrative Staff
Practitioners
Other (Please List)

Other Audience:

Attach sheet to list other learning objectives:

Attach biography/CV/resume:

Additional Comments :

Security code:

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