Speaker request form

Email address

Your organization name, address, and phone number

Contact name, address, and phone number (Please include a cell phone number in case of emergency on the day of the speaking engagement)

Will the presentation be given at the organization address listed above? If not, please provide the name and address of the speaking engagement.

Please provide specific parking details and how to enter the building, if applicable.

What topic(s) would you like to be discussed? Please be specific.

Date and time of presentation

How many minutes are allotted for the presentation and Q&A?

Describe the audience. Please be as specific as possible. (Age, interests, experience, etc.)

Audience Size

Our speaker may use a PowerPoint presentation and bring his/her laptop. Does your facility have a projector and screen?

Are the any additional details that you feel may be necessary for this event?