APTA Speaker Request Form

APTA Speaker Request Form

Thank you for contacting APTA's Public Affairs Unit. In order to better understand and prepare for each presentation/speaking engagement request, we ask that you complete the information below.

Requests must be submitted 3 months prior to the presentation. Those requests made well in advance of the presentation will have a greater chance of being scheduled.

Due to scheduling and work constraints, we may be unable to honor all requests and, in some cases, may suggest alternative presentation methods such as virtual presentations and webinars. Individuals requesting speaking engagements of APTA staff are responsible for covering speaker travel expenses.

A response will be received within 2 weeks of request form submission. If you have any questions please contact APTA's Public Affairs Unit at advocacy@apta.org.

*Requesters are required to update expected attendance to staff 14 days out of the presentation. APTA reserves the right to change the method of presentation if threshold is not met.

Contact and Presentation Information

Contact Information

First and Last Name

APTA Identification No. (if applicable)

Professional Designations

Daytime Phone

E-mail

Contact Person's Affiliation (Select the one that best represents the organization you are affiliated with)

Affiliation Company or Group Name

Presentation Information

Date of Presentation

Requested Topic(s)

Is this request part of a larger conference program?

If yes, what is the title of the program/conference?

Time of Presentation

Duration of Presentation

Location of Presentation

Venue Name

Street Address

Street Address 2

City, State, Zip

Desired Presentation Format

If "Other" was selected above, please describe presentation format.

Is APTA staff person expected to attend other meetings or events?

If you indicated that staff are requested to attend other events, please describe.

Are CEUs offered at this event?

(APTA staff are not responsible for obtaining CEU approval.)

Expected Attendance (Must guarantee at least 25 attendees for travel)

Would an Alternate Method of Presentation be Considered if In-Person is not Available? (If so, please check which methods would be acceptable)

Is AV Available?

Is this an annual event?

Has your group held a presentation with APTA staff in the past 24 months?

Presentation Summary

In the space provided below, please identify any special circumstances for which this topic is relevant and timely for your audience:

In the space provided below, please briefly describe the requirements, information or provide a brief description of the presentation

Use the space below to provide further comments that you feel pertinent to the travel, duration of the trip or presentation.

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