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Speaker Request Form
Name of Alliance Requesting Speaker
Date of meeting/event
Who would you like to address your Alliance?
State President AND Membership Chair
State President AND Health Chair
Any/All State Officers Available
Your Best Telephone Number, including Area Code
Your E-Mail Address (please double check for accuracy)
Which is the best form of contact
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MSMA CME in the Sand
Friday May 25 - Tuesday May 29
AMA Alliance Annual Meeting
Saturday Jun 9 - Tuesday Jun 12
MSMA Alliance Annual Meeting & Officer Installation
Friday Aug 17 - Saturday Aug 18