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Speaker Request Form

First Name(*)

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Last Name(*)

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Department(*)

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UAB Phone Number(*)

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Email(*)

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Meeting Date(*)

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Meeting Time(*)

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Alternate Meeting Date(*)

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Alternate Meeting Time(*)

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Is this a virtual meeting? (*)

Yes

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Parking Information for Speaker (Indicate if parking is available & where)

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Meeting Location (Building, Floor, Room)

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Focus of Speech(*)

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Specific Nonprofit Requested (if applicable)

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Audience

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Size of Group

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Length of time for presentation

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Is a computer and projector available

Yes

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Additional comments or instructions

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(*)

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