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Speaker's Bureau Request
The Presbyterian Healthcare Speaker's Bureau can assist you in arranging a speaker to address your business, group or meeting. If you have any questions please contact us at 704-384-7507.

*Denotes required fields

*Contact Name:    
(First, Middle Initial, Last)
*Organization:  
*Work Phone: - - Ext.
*Email Address:
*Requested Topic:  
Program Dates: * / / (MM/DD/YYYY)
/ / (MM/DD/YYYY)
/ / (MM/DD/YYYY)
Start Time End Time
* Time:
Program Location:  
*Address 1:  
Address 2:  
*City:  
*State:      *Zip:     
Type of Event: Breakfast Fundraiser
Luncheon
Evening Fundraiser
Walk
In-Kind
Run
Other   
*Expected Attendance:
*Age:  (Please check all that apply)    0-34     35-59     60-85     85+

*Race:  (Please check all that apply)   Asian      African-American/Black     Caucasian/White    Hispanic   
Multi-Racial    Native American   Pacific Islander     Other 

Notes:


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