Title
Miss
Mr.
Ms.
Mrs.
Prof.
Other
Name
*
First Name
Last Name
Email Address
*
Phone Number
*
-
Area Code
Phone Number
Name of Institution
*
Institution Type
*
Church/Faith Based
College/University
Corporation
Fraternity/Sorority
Government
Association
Non-profit
Speaker Series
Institutions Website
Department or Student Organization Name
Required if university-based.
Event Name
*
Event Description
*
A brief description of the event's purpose, format, audience, etc.
Date of Event
*
-
Month
-
Day
Year
Date Picker Icon
Event Start Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Event End Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Name of Venue
Venue Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the closest airport and/or Amtrak station?
*
Event Theme/Topic of Presentation
*
How many minutes will the speaker present for?
*
Other requested activities (additional fees may apply)
Question and Answer (after the speech)
Meet and Greet (before or after the event)
Interview/Media Activity
Private Reception/Meal with Invited Guests
If yes, how many minutes will the activity be?
If a panel, what are the names and affiliations of the other panelists?
Name (affiliation), etc
How many people do you anticipate in the audience?
What is the demographic of the audience?
*
high school, college, adults, faith-based, executives, etc.
What will be covered by your organization?
Honorarium
Air or Train Travel
HotelCar Service
Meals or Per Diem
If only honorarium is checked above, are you requesting an all-inclusive speaker's fee?
Yes
No
What is your budget for a speaker?
*
Additional Details/Comments
*
Submit
Should be Empty: