Speaker Request Form
Details of Your Event
Name:
Your answer
Company or Event Name:
Your answer
Primary phone number:
Your answer
Email:
Your answer
Fax number:
Your answer
Complete mailing address:
Your answer
Speaking topic:
Your answer
Date and time of event:
MM
/
DD
/
YYYY
Time
:
Event location (city, state, and hotel/venue):
Your answer
Length of presentation time:
Your answer
Multiple presentations needed? (Ex., Q&A session, photo opportunity, VIP session)
If yes, what type of session?
Your answer
Audience size:
Your answer
Describe the audience. What is their title/occupation? What are the opportunities/challenges? What do they want to learn/take away from the session? What should they do/think/have?
Your answer
What would make this presentation a "success" for your organization?
Your answer
A/V equipment available?
Will you film/record the event?
Your answer
Vendor table available for book/product sales and/or book signing?
Will case of books be purchased in advance for your audience members?
What is your budget for this presentation?
Your answer
What are guidelines for travel budget and arrangements for speakers?
Your answer
Onsite event contact name and cell phone number?
Your answer
Additional information
Your answer
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