Virtual Speaker Registration Form Name(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Suffix Preferred Pronouns She/Her/Hers He/Him/His They/Them/Theirs Other Other: Job Title(Required) Institution Name(Required) PhoneInternational Phone NumberIf you are an international speaker, please type your phone number here. Email(Required) Lecture Date(Required) MM slash DD slash YYYY Lecture Title(Required)Consent to Digitally Record(Required)With permission, the Dept. of MMI will record your seminar. The recording is shared internally for those who may miss the seminar. The recording will not be posted on a public platform. Yes No Upload your Press Photo or Professional Headshot ImagePlease upload a professional photo of yourself. Allowed file types: jpg, gif, png, pdf. Maximum file size is 24 MB. If your file is too large, please email to allison.bauer@wisc.edu separately.Accepted file types: jpg, gif, png, pdf, Max. file size: 24 MB.Upload your Current CV(Required)Accepted file types: doc, docx, pdf, jpg, Max. file size: 24 MB.Upload your Current W-9 Form or Appropriate Tax FormMax. file size: 24 MB.PhoneThis field is for validation purposes and should be left unchanged. Download Blank W9 Form More