Speaking Engagement Request Form

Contact Information
Name of Requester*

First NameLast Name
Organisation/Company*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Event Details
Event Name*
Event Date*

MonthDayYear
Date
Event Location*

CityState / Province

Postal / Zip CodeCountry
Event Context
Event Goal or Theme
What’s the big picture you want this talk to support?
Key Challenges or Needs of Your Audience
Event Audience
Expected Audience Size*
Audience Type

Corporate / LeadershipNGO / Community GroupEducation / University / SchoolConference / FestivalRetreat / Workshop SeriesOther
Audience Demographics

Industry professionalsStudentsGeneral publicOther
Presentation Format
Tell us what you envision
Presentation Format

Keynote (20-60min)Panel discussionWorkshopOther
Duration of Session

Hour Minutes
Equipment/AV Requirements
Additional Information
Budget for Speaker
Please specify currency
Will travel/accommodation be covered if required?

YesN/ANo
Other Requests or Comments
Should be Empty:

Contact Information