Fillable Speaker/Event Request Form (Covered California)

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Speaker/Event Request Form (Covered California)

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The Speaker/Event Request Form (Covered California) form is 1 page long and contains:

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Country of origin: US
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Please attach an agenda for your event.
FOR USE BY COVERED CALIFORNIA
Speaker assigned:
Date
CC file #:
Speaker/Event Request Form
Complete as much information as you have about your event and speaker requirements. Please submit
requests at least four weeks prior to the event. Once completed email the request to:
SpeakerRequests@covered.ca.gov
Date:
Your Organization:
Sponsoring Organization Type of Organization
C
ontact Name Contact Phone
Contact E-mail Website
Yo
ur Program:
Da
te of Program Time of Program
N
ame of Program
T
heme/Purpose of the Program
L
ocation of Program
P
roposed Topic
Requested Speaker (if you are interested in a particular speaker)
Pres
entation Format (panel, speech, roundtable, tabling, etc.) Length of Speaker’s Presentation
Y
our Audience Composition:
Size of audience Audience Composition (consumers, stakeholders, employers, other)
Languages needs?
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SpeakerEvent Request Form (Covered California)

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Completed 19 May 2021

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