Thank you for your interest in having a Hattiesburg Clinic physician or health care representative speak at your event.  We are pleased to help educate our communities regarding health-related topics.  Due to the number of requests we receive, we might not be able to fulfill all requests.  Requests must be submitting four weeks prior to the event to be considered.

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* 1. Organization Name:

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* 2. Organization Mailing Address:

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* 3. Organization City:

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* 4. Organization State:

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* 5. Organization Zip Code:

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* 6. Organization Website:

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* 7. Contact Person’s First Name:

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* 8. Contact Person’s Name Last:

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* 9. Contact Person’s Title:

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* 10. Contact Person’s Phone Number:

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* 11. Contact Person’s Email Address:

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* 12. Please share the mission/vision of your organization:

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* 13. Please describe the program or event in which you are asking Hattiesburg Clinic to provide a speaker.

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* 14. Please list the name, date(s), and location(s) of the program or event.

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* 15. Please provide details regarding the speaking topic.

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* 16. How long are you requesting for the presenter to speak?

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* 17. Please provide approximate number of attendees.

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* 18. Please tell us more about who will be attending this event.

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* 19. Please list the communities for which you are providing this event.

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* 20. Please indicate which of the following items you will provide:

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* 21. Please list any additional details here, including any other information that might help us make this speaking event a success.

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