Speaker Request Form

Speaker Request Form
All speaking requests must be submitted through the webform below. We request that you submit this form along with any supporting materials preferably 6-8 weeks prior to the event date. Please note that all requests will be reviewed before a final determination is made. Please allow 7-10 business days to respond to your request.
Requestor Details
Requestor Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Inviting Organization *
Organization Type*
Organization Website*
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Sponsoring Organization(s) (if different from Inviting Organization)
Budget / Honorarium Offer*
Currency: USD
Event Details
Event Format

Virtual EventIn - Person (Domestic - within the continental U.S.)In - Person (International - external to the continental U.S.)
Virtual Events Only (Specify the video-based platform to be used for the event, i.e., Zoom, MS Teams, Google Meets, Webex, etc).*
Event Name*
Event Type *
Event Description (describe the purpose of the event)*
Event Topic (what would you like Dr. Graves to speak about?)*
Please describe what you hope your audience will gain and/or learn from the speaker? (provide as much detail as possible)
Event Date (first option)*

MonthDayYear
Date
Event Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Event Timezone*
Alternative date options: Please provide additional date options in case your first date selection is not available.
Event Date (second option)

MonthDayYear
Date
Event Time

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Event Date (third option)

MonthDayYear
Date
Event Time

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Deadline to receive speaker confirmation*

MonthDayYear
Date
Speaking Duration (minutes)*
Will there be a Q&A Session*

YesNo
Q&A Session Duration (minutes)*
Address Type*
Audience Size*
Audience Composition & Proportions (Who will be in attendance?)*
Provide details of expected audience members (e.g. educators, senior leaders, students, elected officials, etc.)
Will the event be recorded or published?*

YesNoNot determined
Where will it be published?
What types of media are invited to the event?*

BroadcastPrint and/or WebLocalRegionalNationalMedia not invited
Is an award, certificate, gift or other item being presented to the speaker?*
Is this event open to the general public or invitation only?*
Venue Details
Venue Name *
Venue Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Doors Open*

Hour Minutes

AM/PM Option
Please explain any COVID related restrictions or mandates (i.e., mask mandates, vaccination requirements, state or country regulations)*
Travel
Will your organization pay for travel (Flights, Train, Bus)?*

YesNo
Closest airport / Station*
Will your organization pay for accommodations (Hotel, Lodging)?*

YesNo
Upload any documents that may be relevant to your request (optional)

File Types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
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Please verify that you are human*
Should be Empty:

Speaker Request Form

Requestor Details

Event Details

Venue Details

Travel