Event Speaking Request Form
Event Name
*
Event Date
*
-
Month
-
Day
Year
Date
Event Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Event Theme/Topic
*
Speaker Request
Preferred Speaker
*
First Name
Last Name
Reason for Speaker Choice
*
Contact Information
Name of Requester
*
First Name
Last Name
Organization/Company
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Event Audience
Expected Audience Size
*
Audience Demographics
*
Industry professionals
Students
General public
Other
Logistics
Speaker Session Format
*
Keynote
Panel discussion
Workshop
Other
Event Time
*
Hour Minutes
AM
PM
AM/PM Option
Duration of Session
*
Hour Minutes
Event Format
*
In-Person
Hybrid
Virtual
Equipment/AV Requirements
*
Back
Next
Additional Information
Budget for Speaker $
*
Other Requests or Comments
Information Needed from the Speaker:
*
Professional Bio
Professional Headshot
Other
What area of expertise requesting from Speaker
*
Authorship/Creative Writing
Motivational Speaker
Leadership Development
Business Strategy
Media
Check if organization covers Speaker cost:
*
Ground (Taxi, Ride Share, Train, Parking) Accommodations
Air Fare Accommodations
Reasonable Meals
Other
Is Speaker permitted to sell products at the Event?
*
Yes
No
Will Event be recorded?
*
Yes
No
Submit
Should be Empty: