Speaker Request Form

Welcome to the Department of Neurology Grand Rounds Speaker Schedule Form page.

If you have questions or comments, please send them to Susan Hutton. shutton@med.wayne.edu

 

Neurology speaker Information

*Date of talk (1st Choice):

*Date of talk (2hd Choice):

*Name of Speaker (and degree, e.g. M.D., Ph.D, D.O. etc.):

*Title of Speaker (Professor, Associate Professor, Assistant Professor, etc.):

*Institutional Affiliation:

Phone number of Speaker:

Fax number of Speaker:

*Title of Talk:

*Objective of Talk:

*Supported by an unrestricted educational grant from:

Curriculum Vitae sent via (please select one):

email (lpaul@med.wayne.edu)

fax (313-745-4216)

Audio/Visual needs (Data, Slide, Overhead Projector, etc):

*Contact Person (your name):

*Contact Email (your email address):

*Contact Phone Number (your phone):

Contact Fax Number (your fax):