Speaker Requests

Speaker Requests * All sections must be completed.
Please answer Not Applicable or NA when appropriate.

Your name:

Organization or Company Name:

Job title:

Daytime Phone with Area Code:

Evening Phone with Area Code:

Email:

Name of Speaker Requested:

Website:

Regarding the event for which a speaker is desired, please:

1. state its date and time:

2. identify the facility at
which it will take place:

3. provide the street address (including city, state and zip
code) of the facility at which the event will take place:

4. state the number of people
you anticipate will attend:

5. state the program or meeting
name, topic, and theme, if any:

6. state the program or meeting agenda,
indicating where on it the requested
speaker will be slated and the amount of
time allotted for his or her presentation:

7. identify by name and title, each
speaker to be featured and briefly
describe the topic he or she is to address:

Preliminary Questions and/or Comments:

While we attempt to
respond to all
speaker requests
within 72 hours,
please allow us up
to five (5) business
days to respond
regarding speaker
availability and
costs.

SPEAKER COSTS:

The honorarium for
each speaking
engagement is
negotiated on a
case by case (and
is waived in some
instances), but must
always allow for the
reasonable costs of
transportation,
lodging, and meals,
if any.