Speaker Request Form for
Elected Board Members / Educational Director

This form must be submitted to the IAHCSMM Headquarters in order to process your request. Notification on the status of request will be advised via email within three weeks of receipt of completed form.

IAHCSMM may provide sponsorship for the Educational Director / Elected Officers. Further, IAHCSMM reserves the right to provide sponsorship on a case- to- case basis to any individual promoting the CS profession or the Association (IAHCSMM).

Date(s) of Event:
Location of Event:

Contact Person Name:
Contact Person Email:
Contact Person Phone Number:

Requested Topic: (For a list of topics; contact IAHCSMM):
Date of Requested Presentation:
Time of Requested Presentation:
Length of Presentation: (Presentations are 1.25 hours in length):
Expected Number of Attendees:

What is your Target Audience
CS Technicians CS Managers OR Infection Control Other

Briefly describe how this program supports IAHCSMM’s Mission:


Has your group requested a speaker from IAHCSMM in the past 2 years?	Yes No

Submitted by: