Speaker Request Form
Thank you for your interest in having me at your event. In order to help me facilitate your request, please complete and submit the following form (and any corresponding attachments) to
speakersbureau@cutlassleadership.com
at least 2 weeks prior to the event, and allow 3-5 business days for decisions to be made. Speaking fees vary based on nature of request.
* Required
Email address
*
Your email
Part 1: Event Organizer
Name of Organization Submitting Request:
*
Your answer
Event Sponsor(s):
*
Your answer
For Profit/Not for Profit:
*
For Profit
Not For Profit
Coordinator/Point of Contact: (Name, title, email, office phone, cellphone)
*
Your answer
Part 2: Event Details
Event Name/Title:
*
Your answer
Event Location:
*
Your answer
Event Date
*
MM
/
DD
/
YYYY
Event Time
*
Time
:
AM
PM
Event Type: (conference, dinner, small group, etc.)
*
Your answer
Event Purpose/Goal:
*
Your answer
Event Website: (if applicable)
*
Your answer
Part 3: Presentation/Speech Details
Requested Topic:
*
Your answer
Presentation Format: (keynote address, roundtable, panel,etc.)
*
Your answer
Expected Duration: (30 minutes, 1 hour, etc.)
*
Your answer
Question and Answer: (Will the speech be followed by a Q&A session?)
*
Yes
No
Part 4: Audience Details
Audience: (Approximate size of audience. Also briefly describe its make-up and if membership is required to attend.)
*
Your answer
Honorable Guests: (List names and titles of members of Congress, CEOs, or other VIPs participating in, or attending the event.)
*
Your answer
Media: (Will media be invited? If so, will the event be open or closed press?)
*
Yes
No
Media: (describe and submit media list.)
*
Your answer
Part 5: Additional Information
Deadline for Acceptance:
*
MM
/
DD
/
YYYY
Cost of Attendance: (please include member and nonmember price, if applicable)
*
Your answer
Offer of Payment / Reimbursement: (none, dining, lodging, travel, etc.)
*
Your answer
Disclaimer/Release Form: (Please indicate whether or not the event sponsor will need the speaker to sign a disclaimer/release form.)
*
Yes
No
Please submit speaking requests at least 2 weeks prior to the event.
Please allow 3-5 business days for a decision to be made.
Please submit any corresponding attachments to
speakersbureau@cutlassleadership.com
A copy of your responses will be emailed to the address you provided.
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