Name of the event
*
Purpose of event
*
Event social media link(s) and hashtags
*
Name of host company/organization
*
Point of contact name
*
First Name
Last Name
Title
*
Work Phone
*
(###)
###
####
Mobile Phone
*
(###)
###
####
Email
*
Host company/organization address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Event location
*
Please be specific (i.e., Virtual, Teams, Zoom link, in-person, full address, room number, floor, etc.)
Event date
*
Please provide the specific day of request
MM
DD
YYYY
Event start time
*
Hour
Minute
Second
AM
PM
Event end time
*
Hour
Minute
Second
AM
PM
Event time zone
*
Request type
*
Speaking topics
*
Please be specific
Fomat and run-of-show with exact times
*
Is there anything important to note regarding speaking format? This could include any notes on run-of-show, stage setting, podium, microphone type, whether you'd like a written speech in advance, PowerPoint, etc.
Estimated audience size
*
Audience description/demographics
*
What is your budget for this request?
*
Will travel arrangements be provided / reimbursed?
*
Will audio /visual be provided?
*
Will there be any press/media? If so, who?
*
What do you need?
*
Please be specific (i.e., headshot, long/short bio, etc.)
Additional Notes