Lecture Request

Lecture Request

To schedule a 1-hour activity, please complete the form below.

If you have questions, please use one of the following options:
E-mail: HAELectures@RMEI.com (please include “Schedule a Lecture” in the subject field)
Phone: 1-877-547-5642 (please remember to leave your full name, institution or hospital from which you are calling, e-mail address, and phone number)

Lecture Request
Organization:*
First Name:*		Last Name:*
Academic Degree:*
Address:*
City:*		State:*
Zip Code:*		Phone:*
Fax:		Cell:
E-mail:*
Date and Time Selection
1st Date:*	- :
2nd Date:*	- :
Please allow 2–3 weeks when requesting a meeting.

Venue
Faculty Preference (if any):
Speakers are identified on homepage. If desired, please identify your preferred speaker(s). Please Note: Selections based on Speaker availability.
Location Name:*
Address:*
City:*
State:*		Zip Code:*
Room:*
Contact:
Phone:
Fax:
E-mail:
Head Count:*
Target Audience:*
*Would you like us to supply food & beverage?
*Would you like RMEI to handle accreditation?
If you require audiovisual equipment, please select from the following:
LCD projector Computer Screen
*How did you hear about this program?
Note:
	*Required field
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