Date of Event:
Name of Sponsoring Organization:
Event Address:
Contacts Information: (Cell and/or Office Phone # & E-mail Address)
Organizations Contact Name:
Start Time & End Time:
Event Title:
Is the request for a keynote speaker, guest speaker, panelist, book promo or other (Please Specify)
Theme of Event:
What is the expected talk time?
Who is the audience?
How many members/guests are expected t attend (If applicable):
Are other speakers attending the event?
Is there an honorarium available for the presentation?
Please specify parking location in proximity to the building/venue location
If the event is in a hotel, what is the room name, Hotel Phone & Fax number?
If the event requires for me to travel out of my area, are my travel and hotel accommodations included?
What audio-visual equipment is available? (Ex: Podium, Microphone, Projector, Flip Chart, Projector..)
Additional Information: