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Request a speaker form

I would like to request a speaker to present information on behalf of Health & Community Services Complaints Commissioner’s office
1. Your contact details
Use this section to provide us with the contact details for your organisation
Contact person’s name
Organisation name
Address
Daytime telephone number/s
E-mail address
2. Venue and Presentation Summary
Use this section to tell us what your requirements are for the event
Please tell us what issue or topic are of particular interest
Preferred date of presentation
Please nominate an alternative date
Preferred time of presentation
Please nominate an alternative time
Duration of presentation
Venue and available presentation aids/facilities
Audience details (eg: background, number of attendees, members with special needs)
3. How did you find this Web site?
from a brochure
from a advertisement
from a friend
from a service provider
referral from another organisation
from a search engine
another way, please give details

OR

Fax to 08 8226 8620.

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health & community   services complaints commissioner