Please Complete to Arrange for Dr. Baruch to Speak at your Event

If you would like to have a request considered, please complete and submit this form electronically so that your request may be evaluated.  It is strongly suggested to submit requests as far in advance of the event as possible. PLEASE NOTE:If a podium, microphone, computer and LCD projector will be required for all presentations. All technical requirements must be confirmed prior to the event. (*=required field)

Name: * Title:

Email: *

Name of Organization :

Phone: * Fax:

Address:

Address:

City: State/Province:

Zip/Postal Code: Country:
Event Information

Event Type (Ex: Health Expo, Lecture, etc.)

Title or event name

Address:

Address:

City: State/Province:

Zip/Postal Code: Country:
Location of Event: Proposed date(s)

Speech/Lecture

Dr. Baruch's  outreach approach is currently focused on the following topics. Please select the presentation that you would like delivered at your event:

Health & Wellness

 

Additional Information

What time does the lecture start? AM PM
What is the length of the event? minutes

Expected Attendants

Cost for admission

Length of time Dr. Baruch will be required

Other invited speakers/presenters

Proposed Budget for Dr. Baruch Honorarium

How much space is allotted for vending for Dr. Baruch?

How did you hear about Dr. Baruch?

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