Speaker Request Form
Please fill out the form below to request Tied To Greatness:
Today's Date
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Month
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Day
Year
Date
Organization Name
*
Organization Type
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For or Non-profit
Organization Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization Phone Number
*
-
Area Code
Phone Number
Organization Website
*
Contact Name
*
First Name
Last Name
Contact Work Phone Number
*
-
Area Code
Phone Number
Contact Cell Number
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Area Code
Phone Number
Contact Fax Number
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Area Code
Phone Number
Contact E-mail Address
*
example@example.com
Contact Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Speaker Budget
*
The Event
Name of Event
*
Date of the Event
*
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Month
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Day
Year
Date
Time of Event
*
Length of Presentation
*
Is the event virtual or in-person?
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Virtual / In-person / Unsure
If the event is in-person, please provide the exact address of the venue.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Room Type
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(e.g. Auditorium, Classroom, Gym, etc.)
How will the room be arranged?
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Will you have a photography and videographer recording the event ?
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Yes / No
If yes, can we get a copy of the footage?
Yes / No
Dr. Ellis will need a large screen, projector, laptop, full PA, sound system, and reliable internet. Are these audio/visual accommodations available?
*
Audience
# of Expected Participants
*
Age Range of Attendees
*
Please provide some audience demographic information. (Occupations, ethnicity, education, etc.)
*
Is there an admission or registration fee to attend?
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Yes / No
If yes, how much is the admission or registration fee?
USD $
Is the event open to the general public?
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Yes / No
Is the event open to the media?
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Yes / No
Further Details
If the event is in-person, is transportation to and from the event provided for speakers?
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If the event is in-person, is it possible for Dr. Ellis to arrive 60-30 minutes prior to the event to set up his laptop and presentation to ensure all is running smoothly?
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If the event is virtual, on which platform will the event be held?
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If the event is virtual, will there be a tech rehearsal?
*
Please note any questions or comments you may have:
Submit Form
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