(For planning purposes, please submit no later than 30 days prior to the event…Thank you!)

 
Event date:

Event location:

Theme of requested speech:

Requesting organization:

Organizational focus:

Organizational model (i.e. nonprofit business, church, school, etc.):

Type of speech: (i.e. motivational/inspirational, instructional, interactive, panel discussion, etc.)

Estimated audience size:

Timed allowed for speech and Q&A if applicable:

Other speakers at this event and dignitaries in the audience:

Media Presence?

Audio visual desired?

Handouts desired?

Picture and bio desired?

Proposed fee if applicable:

Expenses covered, if applicable, (please list covered expenses and provide applicable guidance):

Additional information: