Speaker Request Form
Dr. Jesse Sanders, Ph.D
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Email *
Having Relevant Conversation to Redefine Lives in a Radical Way
Primary Contact First and Last Name *
Organization Name *
Email *
Office Telephone Number *
Mobile Telephone Number *
Is the Primary Contact the same as the "Day of the Event" Contact? *
Host Organization *
Organization’s Office Address *
Organization’s Mailing Address *
Type of Organization *
Name of  Event (please include a brief description) *
Event Start Date *
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Event End Date *
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Expected number of attendees
Venue Name
Venue Address
Venue City, State, and Zip Code *
Overall Topic(s) for discussion/presentation *
Date of Speaking Engagement *
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Date of Speaking Engagement *
Time
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Speaker's Role for Speaking Engagement *
Requested length of time for the speaking engagement *
Type of Event *
Description *
If a PowerPoint will be used during a presentation, is it acceptable for the presentation to be provided via flash drive?
If a PowerPoint will be used during a presentation, will a projector and a computer be provided for the speaker? *
Required
Media: (Will media be invited? If so, will the event be open or closed press? Also describe and submit media list.) *
Required
Deadline for Acceptance:
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Cost of Attendance: (please include member and non­ member price, if applicable)
Speaker’s Budget  *
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