Please complete and submit the form below to request Dr. Hatem Bazian to speak at your upcoming event. Event Name(required) Event Date(required) Event Time(required) Expected Number of Attenedees(required) Purpose of the Event(required) Will there be other speakers present? If so, please list them?(required) Event Location(required) Organization Name(required) Organization Website(required) Contact Name(required) Contact Email(required) Contact Phone Number(required) Additional Information
