Speaking Request Form:

Your Full Name? *

Your Email Address? *

What is the name of the event? *

What is the event date? *

What time does event start? *

What is the event venue? *

Event Venue Address? *

City *

State *

Zip *

Parking Available?

Who is my direct contact for the event? *

Contact's Phone Number *

Contact's Email Address *

Do you have a speaker budget?

If yes, how much is it?

How many attendees are you expecting?

Are you charging your attendees?

If yes, how much?

Please describe the targeted audience. (Example: Gender, Age Range, Professionals, Students) *

What do you want the audience to take away from my speech or the event as a whole? (Example: Information, Inspiration) *

Will I have A/V (Audio/Video) access? *

Will a microphone be available? *

Length of talk? *

Total length of time commitment? *

May I have a vendor table? *

May I raffle or donate item? *

Will meals be provided? *

Will there be a professional photographer?

If yes, will I receive copies of event photos?

Will there be a professional videographer?

If yes, will I receive a copy of the event's video?

Out-Of-State Speaking Requests:

Travel, lodging and accommodations provided? (Example: Airfare, Hotel)

Ground transportation provided?

Travel accommodations for assistant?