Speaking Engagement Request Form
We ask that this information be completed and sent via email at least 7 days prior to the event.
Organization/ Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Date
-
Month
-
Day
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Possible # of Attendees:
*
Theme of Event
*
Requested service
*
Workshop
Seminar
Conference
Graduation
Social Media live
Webinar
Youtube
Media
Talk Show
Other
Which platform will the event be taking place?
*
Google Meet
Zoom
Face-to-face
Other
Speaker Topic
Who will attend? Please indicate the names and tittle of leaders within the organization the speaker must Acknowledge in opening remarks.
*
Demographic information ( Select which Applies).
*
Male only
Female only
Both
Children
Teenagers
What is the average age of the audience?
What is the education level of the audience?
What are the sensitive issues? Are there controversial issues that should be avoided?
What frustrations do they experience as they provide services to your organization?
What is the biggest challenge your company/ group is facing today?
What are the strategic goals of the organization?
What information might be helpful for the speaker to know?
How do you want your people, students', servicemen/ women to feel when they leave the speaker's presentation?
How did you hear about Anna-kay McGhan?
Social media
Google
Friends
Other
Save
Submit
Should be Empty: