Anthony Ianni Speaking Request Form
Use this form to request a presentation
Type of Request(s) *
Please indicate the type of request
Required
Host Organization *
The name of the school or organization hosting the event
Your answer
School District *
The name of the host's K-12 school district
Your answer
Host Address *
Your answer
Host Address 2
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Presentation Location *
Will the event be at the Host Address or a different location (please provide)?
Required
Reduced or Free Lunch *
If your State of Michigan school provides 40% or more free and reduced lunches, the speaker’s fee is waived.
Required
Date Requested - First Choice *
When would you like to host this event?
MM
/
DD
/
YYYY
Time
:
Date Requested - Second Choice *
When would you like to host this event
MM
/
DD
/
YYYY
Time
:
Date Requested - Third Choice *
When would you like to host this event
MM
/
DD
/
YYYY
Time
:
Point of Contact *
Person Responsible for Arrangements
Your answer
Contact Phone *
Your answer
Contact Email *
We must have a valid email address to reach you through the automated system - thank you.
Your answer
Intended Audience(s) *
As best as possible, please indicate the intended audience (all that apply)
Required
Number of participants in the session
What is the likely total number of participants
Your answer
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