Speaking Request Form
with H.I.P.S. CONSULTING
Contact Name
*
First Name
Last Name
Organization/ Department
Type of Speech
Please Select
Welcome
Introduction
Keynote
Closing Remarks
Other
If "other" please describe here
Date of Speaking Engagment
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Month
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Day
Year
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Time of Event
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Hour
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Minutes
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PM
AM/PM Option
until
until
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:
Hour
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10
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Minutes
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AM/PM Option
Event Location
Event/Group to be addressed
Reason for Speaking Request
Length of speaking time (minutes)
Approximate Speaking Time
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Event/Organization Background
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Contact Phone
*
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Area Code
Phone Number
E-mail
*
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