Speaker Request Form
Name of your event/group
Your answer
Date and time of your event
Your answer
Location of your event
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Primary contact name
Your answer
Primary contact email address
Your answer
Primary contact telephone number
Your answer
What topic would you like to see presented at your event?
Your answer
How long is the session for which you need a speaker?
How many attendees do you anticipate at your event?
Your answer
If this is a paid event, what is the cost per attendee?
Your answer
Which of the following best describes your audience?
Is your audience primarily women, primarily men, or a mix of both?
How is this event being promoted?
Your answer
As a speaker, will my information be included in your promotional materials?
Are vendor spaces available for the event?
Will there be other speakers at this event?
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