JACK BREWER REQUEST FORM
Name of Organization(s):
*
Please list the name(s) of the organization(s) requesting
Description of Organization(s):
*
Point of Contact:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Type of Participation:
*
Please Select
Meeting
Remarks
Keynote
Ceremony
Media
Virtual Meeting
Name of Event:
*
Please note official title of the event
Date of Event:
*
If no date has been determined, please list 2-3 days that work for your organization.
Time of Event:
*
Hour Minutes
AM
PM
AM/PM Option
Location of Event:
*
Description of Event:
*
Please provide a 2-3 sentence overview with a general synopsis of your event and how you envision Jack Brewer’s participation. Please also include a draft agenda or run-of-show with all possible speaking slots available. This field must be filled out to be accepted.
Topics:
*
If you are requesting Mr. Brewer to speak, please provide a description of topics you are requesting him to address.
Start time for Mr. Brewer’s participation:
*
Hour Minutes
AM
PM
AM/PM Option
End time for Mr. Brewer’s participation:
*
Hour Minutes
AM
PM
AM/PM Option
Duration of Mr. Brewer’s remarks:
*
Who would introduce Mr. Brewer:
*
Press:
*
Open
Closed
Comms / Marketing Contact for event:
*
Please provide press contact name and email address
Number of expected attendees:
*
Other Invited Speakers (please include all elected/appointed officials):
*
Please note here who else is invited to speak and/or share a stage with Mr. Brewer.
Attire:
*
Closest Airport :
*
(Please list name of airport and estimated distance from your event)
Major City :
*
(Please list city name and distance)
Parking and Entrance Instructions:
*
(Please list city name and distance)
Submit
Should be Empty: