New Jersey Department of Health

Communicable Disease Service

PO Box 369

Trenton, NJ 08625-0369

SPEAKERS’ BUREAU REQUEST

Please print clearly – use a separate form for each request.

Fax completed form to the attention of Suzanne Miro at 609-826-4874.

Date of Request:
Name of Requester:
Title:
Daytime Telephone No.:	Email:
Agency:
Address:
City:	State:	Zip:
Date of Presentation:	Time:
Length of Presentation:
Audience type:

(e.g., public group, physicians, health officers, nurses, etc.):
Audience Size:
Topic Requested:
Location of Presentation:
*Important: Please forward a copy of agenda, if available.

FOR NJDOH USE ONLY
Date Request Received	Name of Speaker Provided	Number in Attendance:
CDS-26

AUG 12

CDS-26, Speaker Request

CDS-26, speakers' bureau, request, speaker, speech, communicable disease service

ewhite

2012-03-19

NJDOH