Speaker Request Form
Please answer the questions in as much detail as possible.
Company/Organization/Group Leader/President *
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Website
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Primary Event Contact Name *
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Primary Event Contact Phone Number *
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Primary Event Contact Email *
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Date of the Event *
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Location of the Event *
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Number of Attendees Expected *
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Purpose of the Event (What do you participants to walk away with?) *
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Format: In what capacity/role would like Dr. Donaldson to participate? *
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Topic of Interest: What would you like Dr. Donaldson to speak about? *
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Audience: Who is your audience? *
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Speaking Time: How long would you like Dr. Donaldson to speak/present? *
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Event Website
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Promotion Plan: TV, Radio, Flyer, Internet, Other
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What are you proposing to offer as a speaker fee? *
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Have you budgeted travel and lodging, if necessary? Please explain. *
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