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BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING PO BOX 944210, Sacramento, CA 94244-2100 P (916) 322-3350 | TTY (800) 326-2297 | www.rn.ca.gov
SPEAKER REQUEST FORM (Submit at least 3 weeks in advance)
TODAY’S DATE: EVENT DATE/TIME: ALT. DATE/TIME:
ORGANIZATION NAME: TYPE OF ORGANIZATION:
MEMBERSHIP INTERESTS/CONCERNS:
TYPE OF EVENT:
TOPICS OF INTEREST:
TYPE OF AUDIENCE: ANTICIPATED AUDIENCE SIZE:
PRESENTATION START TIME: DESIRED LENGTH OF PRESENTATION:
TIME FOR Q & A? YES NO LENGTH OF TIME FOR Q & A:
METHOD OF PRESENTATION: SKYPE/WEBEX TELECONFERENCE IN PERSON
ARE TRAVEL FUNDS AVAILABLE? YES NO
IS PARKING AVAILABLE? YES NO IS PARKING FREE? YES NO
EVENT LOCATION:
AVAILABLE EQUIPMENT: PROJECTOR COMPUTER TABLE FOR MATERIALS
CONTACT NAME: CONTACT PHONE NUMBER:
CONTACT EMAIL ADDRESS:
Submit the completed form by clicking on the button above. Please attach a copy of any flyer or brochure you will disseminate. Completed forms may also be submitted to:
Board of Registered Nursing
ATTN: Speaker Requests
Email Address: [email protected]
Fax: (916) 574-7700 Form for optional use. (1/2019)
