Speaker Request Form

Name (required)

Organization

Telephone Number (required)

Email Address (required)

Type of Event
ConferenceFundraiserGalaKeynotePanelReligious OrganizationSchool PresentationWorkshopOther

Date(s) of the Event

Time of the Event

Desired Length of Presentation

Location of Event

Who is your audience?

How many participants do you expect to attend?

Please provide a brief description of your event.

What would you like the presentation to cover?

Do you have a projector for a Power Point Presentation?
YesNo

Are you able to provide an honorarium of $50 or more to cover our costs?
YesNo