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Speaker Request Form
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Event Details
Event Title
Is the speaking engagment in-person or virtual?
(Required)
In-person
Virtual
Either
Speaking Date
(Required)
MM slash DD slash YYYY
Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Time Zone
(Required)
(GMT -12:00) Eniwetok, Kwajalein
(GMT -11:00) Midway Island, Samoa
(GMT -10:00) Hawaii
(GMT -9:00) Alaska
(GMT -8:00) Pacific Time (US & Canada)
(GMT -7:00) Mountain Time (US & Canada)
(GMT -6:00) Central Time (US & Canada), Mexico City
(GMT -5:00) Eastern Time (US & Canada), Bogota, Lima
(GMT -4:00) Atlantic Time (Canada), Caracas, La Paz
(GMT -3:30) Newfoundland
(GMT -3:00) Brazil, Buenos Aires, Georgetown
(GMT -2:00) Mid-Atlantic
(GMT -1:00 hour) Azores, Cape Verde Islands
(GMT) Western Europe Time, London, Lisbon, Casablanca
(GMT +1:00 hour) Brussels, Copenhagen, Madrid, Paris
(GMT +2:00) Kaliningrad, South Africa
(GMT +3:00) Baghdad, Riyadh, Moscow, St. Petersburg
(GMT +3:30) Tehran
(GMT +4:00) Abu Dhabi, Muscat, Baku, Tbilisi
(GMT +4:30) Kabul
(GMT +5:00) Ekaterinburg, Islamabad, Karachi, Tashkent
(GMT +5:30) Bombay, Calcutta, Madras, New Delhi
(GMT +5:45) Kathmandu
(GMT +6:00) Almaty, Dhaka, Colombo
(GMT +7:00) Bangkok, Hanoi, Jakarta
(GMT +8:00) Beijing, Perth, Singapore, Hong Kong
(GMT +9:00) Tokyo, Seoul, Osaka, Sapporo, Yakutsk
(GMT +9:30) Adelaide, Darwin
(GMT +10:00) Eastern Australia, Guam, Vladivostok
(GMT +11:00) Magadan, Solomon Islands, New Caledonia
(GMT +12:00) Auckland, Wellington, Fiji, Kamchatka
Is the date/time flexible for when the speaker(s)/panelist(s) speak?
(Required)
Yes
No
Location
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
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Belize
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Bosnia and Herzegovina
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Brazil
British Indian Ocean Territory
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Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
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Congo
Congo, Democratic Republic of the
Cook Islands
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Croatia
Cuba
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Côte d'Ivoire
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Djibouti
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Ecuador
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Equatorial Guinea
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Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
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Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
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Honduras
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
You can learn more about our Invention Ambassadors and which speaker is right for your event
here
Requested Speaker
(Required)
A specific speaker is not being requested
Corinne Augelli-Szafran – Southern Research Institute, NAIMem
Issa Batarseh, FNAI – University of Central Florida, NAIMem
Karen Burg, FNAI – University of Georgia, NAIMem
Almesha Campbell, HonNAI – Jackson State University, NAIMem
Dedric Carter – The University of North Carolina at Chapel Hill, NAIMem
Shigao Chen, FNAI – Mayo Clinic, NAIMem
Rory Cooper, FNAI – University of Pittsburgh, NAIMem
Atam Dhawan, FNAI – New Jersey Institute of Technology, NAIMem
Anne DiSante – Michigan State University, NAIMem
Rob Duncan, FNAI – Texas Tech University, NAIMem
Anna Leese de Escobar, FNAI – Technology Vector, Inc.
Kenneth Ford, FNAI – Florida Institute for Human and Machine Cognition (IHMC), NAIMem
Tatiana Litvin-Vechnyak, HonNAI – Georgetown University, NAIMem
Erick Jones – Tompkins Ventures
Mihri Ozkan, FNAI – University of California, Riverside, NAIMem
Jamie Renee, HonNAI – National Academy of Inventors
Dana Vouglitois, HonNAI – Florida Atlantic University, NAIMem
Speaker Information
If your requested speaker is unavailable, please provide a brief description of the characteristics you are looking for in a speaker (e.g., experience (inventor, VP Research, Tech Transfer, etc.), technical background, etc.)
The NAI Invention Ambassador program, created in partnership with USPTO, is aligned with our objective to increase the number of diverse individuals participating in invention.
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Are you looking for a diverse speaker?
Women
Veteran
Black or African American
American Indian and Alaska Native
Asian
Native Hawaiian and Other Pacific Islander
Hispanic or Latino
Person with disability
Other
Other
Please give a description or background on what you would like the speaker to address.
(Required)
Confirmed or other invited speakers/panelists
Name
Title
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If no other speaker is invited, please enter N/A. If other speakers are to be determined at a later date, please enter TBD
Event Information
Hosting Organization
(Required)
Background or purpose of the event
(Required)
Inform the purpose, content and goals of the event to potential attendees
Proposed Speaker Role
(Required)
Fireside Chat
Panelist
Brief Remarks
Presentation
Speech
Symposium Host
Podcast
Other
Other
(Required)
Do you anticipate audience Q&A's?
(Required)
Yes
No
Expected number of attendees
(Required)
Composition of the audience (e.g. patent attorneys, academics, business executives, federal employees, inventors, policymakers, students, NAI chapter members, etc.)
(Required)
What is the audience's expected level of IP knowledge?
(Required)
None
Beginner
Average
Expert
Is the media expected to be in attendance?
(Required)
Yes
No
Will the presentation be recorded or made public?
(Required)
Yes
No
Is there any attendance fee?
(Required)
Yes
No
Fee amount
(Required)
If travel expense(s) are being offered, please indicate the nature of the expense.
Expense type
Amount
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For example, ground travel, airline, hotel, meals, etc.
Requester Contact Information
Name
(Required)
First
Last
Title
Organization
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
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Email
(Required)
How did you hear about this program?
NAI Social Media
NAI Newsletter
USPTO Social Media
USPTO Website
Word of Mouth
Other
Other
Are you the event point of contact?
(Required)
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No
Event Point of Contact
Event Point of Contact
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First
Last
Phone
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Email
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For more information or questions, please email
[email protected]