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University of Kansas Cancer Center
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Speaker Request

If you are interested in requesting a speaker for your upcoming event, please complete this form or
contact Erica Brown, (913) 588-2598. Asterisk (*) denotes required fields.

CONTACT INFORMATION
First name*
Last name*
Phone* (000) 000-0000
Fax (000) 000-0000
Email*

EVENT INFORMATION
Event Title*
Start Date   
End Date   

LOCATION OF EVENT
Street Address*
Building, Room, or Suite Number
City*
State*
Zip code

EXPECTATIONS
Number of people attending
Type of audience
(volunteers, business leaders, etc.)
Expectations
Example: "Dr. Jensen will provide an update on progress towards NCI designation."
Date Response Needed*   
Additional Comments