NSC Speaker Request Form | National Safety Council

NSC Speaker Request Form

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

Please complete the form to get more information.

Here is a list of NSC Experts.

Complete the form to share information about your speaker needs and upcoming event. It may take a week or two to fully evaluate your request, so advance notice is appreciated.

For questions about the NSC Speaker Request process, please contact media@nsc.org.

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?*

NSC Contact Name:

Event Details:

Is your event being held in-person?*

If YES (In-Person):

Please provide specifics on how you plan to manage COVID risk for your event, i.e. social distancing, masking, vaccine requirements, etc.

Provide link or document for safety guidelines being followed by your event location:

Event Location

Event Address

Event Address 2

Event City

Event State

Event Zip

Event Country

Event Name*

Event Date*

Event Start Time

Event Time Zone*

Presentation Type*

Presentation Topic*

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

Number of Attendees*

Audience Description*

Event Description*

Event URL

Event Sponsor*

Confirmation Date Requested By*

Do you have a preferred speaker in mind?*

If preferred speaker is unavailable, would you be open to an alternate presenter?

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

Is compensation available for travel expenses?*

Is compensation available for a speaker honorarium?*

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

Any information about the event:

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.*

For questions about the NSC Speaker Request process, please contact media@nsc.org.

Contact Information:

Host Organization Details:

Event Details:

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