Speaking Engagement Request

Speaking Engagement Request

Please complete and submit the form below to request a speaker; we ask that you give us up to 2 weeks to get back with you. You can always follow up by email at admin@veronicasvoice.org to verify your request was received.
Please read before you continue.
Your Name*

First NameLast Name
Title
Your E-mail Address
Speaking topic your seeking*
Tell us about your group/organization.
Organization name*
Organization type
Org. Phone Number*

Area CodePhone Number
Contact Phone Number*

Area CodePhone Number
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requested length of presentation?
Honorarium amount $.

If you cannot do an honorarium what is your group able to do? What we can do
Some ideas: collect donation from audience, do a needs drive etc..
Email you our current needs list?
Table will be made available?
I understand that it is a requirement to pay mileage for the speakers travel.
Date and time options you're requesting for speaking engagement.
Date option #1*

MonthDayYear
Date
Time*

:HourMinutesAM/PM Option
Date option #2

MonthDayYear
Date
Time

:HourMinutesAM/PM Option
Date option #3

MonthDayYear
Date
Time

:HourMinutesAM/PM Option
Define the speaking engagement details you're requesting.
Name of Requested Speaker, if any
Request survivor as speaker
Location for event*
Will record presentation*
If yes, what format?
How did you hear about us and do you have any special request?
Thank you!

We will be in touch soon to finalize all the details.
Should be Empty:

Speaking Engagement Request

Tell us about your group/organization.

Thank you!