NSC Speaker Request Form | National Safety Council

NSC Speaker Request Form

Would you like to request an NSC Speaker at your next event?

Please complete the form to get more information.

Here is a list of our NSC Experts.

NSC Speaker

Contact Information

First Name*

Last Name*

Phone Number*

Email*

Host Organization Details:

Host Organization Name*

Street Address*

Address 2

City*

State*

Zip*

Country*

Type of Organization*

Is your organization a National Safety Council member?*

Do you have a contact at NSC?*

Contact Name

Event Details:

Event Address*

Event Address 2

Event City*

Event State*

Event Zip*

Event Country*

Event Name*

Event Type*

Presentation Topic*

Event Description*

Event URL

Event Sponsor*

Number of Attendees*

Event Date*

Event Start Time

What is the total presentation length Including questions and answers?*

Confirmation Date Requested By*

Audience Description*

Do you have a preferred speaker in mind?*

Are you requesting a presenter with medical expertise from our Physician Speakers Bureau?*

Are CME credits provided?

What is your budget for the Physician's Speakers Bureau speaking fee?

The speaking fee is $2,000 for the first day and $650 for each additional day. Webinars are $1,000.

If applicable, what is the partial amount available for the budget of the Physician's Speaker's Bureau speaking fee?

Any other scheduled speakers?

Event open to the press?*

Event Press Details

Event to be broadcasted?*

Event Broadcast Details

Any other information that may help clarify your request?

Is compensation available for travel expenses?*

Is compensation available for a speaker honorarium?*

Compensation Amount for Speaker Honorarium

Is this event or any part of the event a fundraiser?*

Terms and conditions: I agree that no person for reason of race, color, sex, religion or national origin, will be excluded from or segregated within membership in sponsoring organization, attendance at event or any of the facilities housing this event. I also agree to receive communications from NSC about the Speakers Bureau.*

Contact Information

Host Organization Details:

Event Details:

Our Mission