Speaker Request Form

Speaker Request Form

Thank you for contacting the Duke-Margolis Center for Health Policy.

To ensure that we have information to evaluate each request, we ask that you provide the following information. Please fill out the speech request form as completely as possible, and we'll respond by e-mail.

Please note that submitting a speech request does not guarantee approval. All speech requests will be confirmed or declined by e-mail.

About Your Group

About Your Group

Contact Person for Content
Contact Person for Logistics
About Your Event

About Your Event

Type/Format of Event
Time Allotted to Speak
Number of People Expected
Event Logistics

Event Logistics

Travel & Honorarium
Are milage or transportation expenses provided?
Type of Airfare Covered
Type of Ground Transportation Provided
Is travel arranged in-house?
Honorarium Provided?
Event Promotion
Will the event be promoted on a website?
Will sponsor need a digital photo of the speaker?

Other useful information:

  • Copies of any schedule/agenda for the event
  • Any scripts for Dr. McClellan and/or other speakers and any additional background information that might be useful
  • Specific address and driving directions to your event
  • Parking information
  • Any press release produced by your event organizers
  • Background information or speech guidelines
  • On-site contact information
Maximum 3 files.
20 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.