Form Cms-20040 - Regional Office Meeting/speaker Request

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Regional Office Meeting / Speaker Request Form
Instructions: Complete both pages of this form, and fax it to the appropriate Regional Office.
FAX Numbers
Boston Regional Office (Region 1):
617-565-1339
Dallas Regional Office (Region 6):
214-767-6400
New York Regional Office (Region 2):
212-264-6189
Kansas City Regional Office (Region 7):
816-426-3548
Philadelphia Regional Office (Region 3):
215-861-4140
Denver Regional Office (Region 8):
303-844-6374
Atlanta Regional Office (Region 4):
404-562-7162
San Francisco Regional Office (Region 9): 415-744-3517
Chicago Regional Office (Region 5):
312-353-0252
Seattle Regional Office (Region 10):
206-615-2027
Event Location
Event Name:
(full street address
required):
Event Date(s) / Time:
Sponsor Name / Type:
Contact Phone /
Contact Name / Title:
e-mail:
Assessment (please circle or highlight)
Speaker
Moderator/Panel
Exhibitor
Meeting Attendee
Other (note below)
CMS Role:
Education / Training
Meeting / Conference
Health Fair
Local Media Interview
State or Regional Media
Type of Event:
Interview
100-149
250-299
50-74
26-49
1-25
200-249
Projected Attendance:
75-99
300+
150-199
Leaders
Front-line educators
Mid level managers /
Beneficiaries
Level of Audience:
coordinators
National
Regional
Local
Media Coverage:
Regional/National
State
County
Local
Geographic Breadth:
Rural
Low-Income
Ethnic
Disability
Information Intermediary
Special Target Area:
(indicate ALL that apply)
CMS-20040 (12/05) EF 12/2005

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