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COMPETENCY SPEAKER REQUEST FORM
Please complete this form to request that a representative of the Lawyer Assistance Program conduct a free MCLE presentation on the specialty Competency credit.
1. Requester Information
Today's Date:
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Requester's Name/Title:
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Requester's Full Address:
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Email Address:
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Phone Number:
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2. Organization/Event/Audience
Name of Organization:
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Type of Organization:
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Bar Association
Conference
Convention
Government
Law Firm
Law School
Non-Profit Organization
Other
Name of Event:
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Name/Title of Coordinator:
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Email Address:
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Phone Number:
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Who is the Audience?
Maximum estimated No. of Attendees:
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URL, if any, for Event:
3. Date/Event/Location
The months of June and July 2023 are not available.
Date of Event (1st choice):
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Time:
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Date of Event (2nd choice):
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Time:
Date of Event (3rd choice):
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Time:
Will this presentation be held in-person or online?
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In-Person
Online
What platform?
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Zoom
Teams
Webex
Other
If other, specify:
Full address location:
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4. Topic/Format
Topic for Presentation:
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Format for Presentation:
(one speaker, panel, etc.)
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Length of Presentation:
(MCLE credit must be
a minimum of 1 hour)
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Are written materials required or desired?
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Yes
No
Are you an MCLE approved provider?
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Yes
No
If yes, what is your provider number:
Additional Info:
How did you learn about our MCLE presentation?
5. Available Equipment On-Site
Which of the following do you have on-site for the program?
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Projector and Screen
TV with HDMI
Internet/Wi-Fi
Microphone
Laptop
Contact