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Event Theme/Purpose

Speaker Topic Request: (Please provide a brief description of the topics or message you would like Dr. Mason to speak on.)*

Duration of Speaking Session

Travel Arrangements: (If applicable, please detail what travel accommodations will be provided, such as flight, hotel, transportation.)

Honorarium Offered: (If applicable, please include honorarium amount or range.)*

Additional Notes or Requests: (Please provide any other details or requests that would be helpful for us to know.)

I understand that submission of this form doen not guarantee that Dr. Mason will be able to participate in our event. I also acknowledge that further discussion will be needed to confirm the details and availability.