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 *
Full Name: *
Phone number: *
Coordinator/Point of Contact: (Name, title, email, office phone, cellphone) *
Name of Organization Submitting Request: *
Event Name: *
Event Location: *
Event Date/Time: *
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/
DD
/
YYYY
Event Purpose/Goal: *
Requested Topic: *
Presentation Format: (keynote address, roundtable, workshop, panel, etc.) *
Expected Duration: (30 minutes, 1 hour, etc.) *
Audience: (Approximate size of audience. Also briefly describe its make-up (age, gender, etc) and if membership is required to attend.) *
Media: (Will media be invited? If so, will the event be open or closed press? Also describe and submit media list.) *
Cost of Attendance: (please include member and nonmember price, if applicable) *
Event Budget: *
Offer of Payment/Reimbursement:(none, dining, lodging, travel, etc.) *
Other notes or requests
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