NYMHCA Speaker's Bureau Sign-up Form

Date:

First Name:

Last Name:

Home Address:

Home Phone:

Work Phone:

Email Address:

Area(s) of Specialization or Study:

County:

Credentials:  (degrees, certifications, licenses)

My Website:

Fax:

Business Address:

County:

I want my website address listed on the Speaker's Bureau page.

Yes/No

The best times/days to contact me:

I am willing to travel the following number of miles from my home:

I require travel expenses:

yes/no

I require an honorarium:

yes/no

If yes, how much:

What topics are you interested in presenting?  Please the numbers which appear next to the discussion topics listed on the Speaker's Bureau page:

  For example:  Topics: 7,9, 21 and 25

Comments:

If you prefer you can print off this form and mail it to:  NYMHCA, 206 Greenbelt Parkway, Holbrook, NY, 11741