Tiana S. Clark - Speaker Request Form
Name
*
First Name
Last Name
Your Email Address:
*
example@example.com
Organization or Company Name
*
Event Name
*
Website
if applicable
Venue Location or Virtual?
*
e.g. Hotel, XXXX Street, Brooklyn, NY (if not virtual)
Event Date
*
/
Month
/
Day
Year
Event Time
*
Hours Minutes Minutes
AM
PM
AM/PM Option
Is this part of a larger event? Is this part of a series or conference?
Yes
No
Other
What is the objective of this speaking engagement? What would you like the audience to walk away with?
*
How much time is allotted for the presentation?
*
Will there be additional time for Q&A?
*
If so, how much time?
What role would you like Mrs. Clark to play?
*
Keynote Speaker
Panel Moderator
Panel Participant
Workshop Leader
Award Presenter
Interview (or Fireside Chat)
Multi-Media Guest (e.g. podcast, video)
Other
Who will be in your audience?
*
eg. students, executives, all levels
How many attendees are expected?
*
What is the attire for the event?
Event Media
What audio accommodations will be provided? Do you require any special equipment for virtual settings? Will the speaker use a lapel or hand-held microphone? Will the speaker share the stage with ASL interpreters?
*
Will there be audio/visual capability for projecting content?
*
Yes
No
Will a media team be present?
*
Yes
No
Will the event be recorded?
*
Yes
No
Speaker Accommodation
Who will be Mrs. Clark's point of contact on the day of the event? Include name, email, and contact number.
What is your speaker budget for this event?
*
Will Mrs. Clark need to travel to attend this event? She is based in the Chicago area.
*
Yes
No
Other
Will your team cover the cost of travel?
Yes
No
Other
Where will Mrs. Clark be met on arrival? Are there any security instructions we should be aware of Where will Mrs. Clark park? Will Mrs. Clark sit with the audience or wait backstage before speaking?
Are there any notable invitations or guests we should be aware of?
e.g. confirmed company executive or public figures
What other information about this event would you like us to know?
If Mrs. Clark is unavailable, would you like recommendations for alternative speakers?
Yes
No
How did you connect with Mrs. Clark?
Submit
Should be Empty: