Devin Burke: Speaker Request Form
Thank you for your interest in having a Devin Burke speak at your upcoming event. In order to help us facilitate your
request, please complete and submit the following form
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Email address
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Your email
Full Name:
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Your answer
Phone number:
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Coordinator/Point of Contact: (Name, title, email, office phone, cellphone)
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Your answer
Name of Organization Submitting Request:
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Your answer
Event Name:
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Your answer
Event Location:
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Your answer
Event Date/Time:
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YYYY
Event Purpose/Goal:
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Your answer
Requested Topic:
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Your answer
Presentation Format: (keynote address, roundtable, workshop, panel, etc.)
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Your answer
Expected Duration: (30 minutes, 1 hour, etc.)
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Your answer
Audience: (Approximate size of audience. Also briefly describe its make-up (age, gender, etc) and if membership is required to attend.)
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Your answer
Media: (Will media be invited? If so, will the event be open or closed press? Also describe and submit media list.)
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Your answer
Cost of Attendance: (please include member and nonmember price, if applicable)
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Your answer
Event Budget:
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Offer of Payment/Reimbursement:(none, dining, lodging, travel, etc.)
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Your answer
Other notes or requests
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