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Maya Brown Speaker Request Form
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Name of Organization Submitting Request:
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Your answer
Description of Organization:
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Your answer
Contact Person:
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Your answer
Contact Office Phone:
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Your answer
Contact Day-of Phone:
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Your answer
Contact Email:
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Your answer
Event Title:
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Your answer
Event Location(Venue/Street Address/City/State):
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Your answer
Event Date:
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YYYY
Event Start Time:
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Time
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AM
PM
Event End Time:
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Time
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AM
PM
Maya's requested participation start time:
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Time
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AM
PM
Maya's requested participated end time:
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Time
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AM
PM
What is the purpose of this event?
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Your answer
If Maya is unable to attend, would you be interested in another member of the MB Strategies team as a speaker?
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Yes
No
Topic of Presentation:
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Your answer
Length of Requested Presentation:
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Your answer
Type of Presentation:
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Keynote Address
Panel
Q&A
Interview
Training
Other:
If panel, please provide a list of other invited and/or confirmed panelists.
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Your answer
Will there be a Q&A?
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Yes
No
Past Speakers:
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Your answer
Expected Audience Size:
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Your answer
Deadline for Acceptance:
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MM
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DD
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YYYY
Cost of Attendance (registration, etc):
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Your answer
Offer of Payment/Reimbursement:
(Check All That Apply)
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Travel Per Diem
Hourly Retainer
Services Rendered In-Kind
Other:
Required
Expected Media Coverage:
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Your answer
Additional details?
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Your answer
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