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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