Speaker Proposal Form

If you wish to make a presentation proposal, please complete and submit the following form in its entirety, as only complete forms will be considered. It is the Texas Hospital Association's policy to review all completed applications and file them for consideration on appropriate programs. THA requires speakers to provide information in an educational, non-commercial, non-self-promotional manner.

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Submitted by:

Name:
Title:
Company:
We are a:	THA Corporate Sponsor HealthSHARE Endorsed Company THA Member
* Phone:	-  -  EXT
E-mail:

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Presenter Information

Name:
Company:
Title:
Credentials:
Address:
City:	State:  ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY ZIP:
Country:
* Phone:	-  -  EXT
Fax:	-  -
E-mail:

 

 

 

 

 

 

 

 

 

Proposed Presentation Title:
 

Target Audience:

Governing Boards	Director/Department Head
CEO	Senior Administrative Staff
CNO (Chief Nursing Officer)	Physicians
CFO	Nurses
Other (please list):

Attach sheet to list additional learning objectives:

 

Additional Comments:

* Required Fields