This form is a preliminary tool for gathering information; it is not a confirmation of your speaking engagement. After you submit this form, we will email you to discuss the options. Today's Date Your Contact InformationName First Last Email Job TitleOrganizationHave you heard a Kaiser Permanente speaker before? Please mention where and when.Please check the box beside the category that most closely identifies the organization that is sponsoring the conference or other event. Government Hospital (including clinics) Health plan Consultant Vendor Professional association University Other How did you hear about Kaiser Permanente? Please check all that apply. KP International email KP International website A colleague in my country Someone I know at Kaiser Permanente International Federation of Health Plans (iFHP) A previous visit to Kaiser Permanente A Kaiser Permanente speaker at a conference Other Goals of Your EventWhat is the theme or focus of your conference or other event?Please describe the composition of the audience. How many participants are expected? What are their positions and organizations?What topics would you like the Kaiser Permanente speaker to cover? What do you hope the audience will learn from this presentation?What is the English language level of the audience? You may select more than one response. If necessary, please arrange for an interpreter. Advanced level or native speaker High level Intermediate level Beginner level or no English Date and LocationWhat is the date of your conference or other event? If you are considering more than one date, please list your first choice date here. If you are considering more than one date, please list your second choice date here. Where will your conference or other event take place? In addition to the city/country, please describe the venue (such as a conference hall, an office building, and so on).Please note: This form is a preliminary tool for gathering information. Completion of this form does not obligate payment or guarantee a speaker for your event. We will contact you to discuss the options. Fees for Kaiser Permanente speakers abroad are US $7,500 per day in North America and Latin America, and $10,000 per day on all other continents. These fees are in addition to travel expenses. If you decide to proceed, your organization must sign a contract to confirm the speaking engagement.* Please check here to indicate you have read the above statement. This iframe contains the logic required to handle Ajax powered Gravity Forms.