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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