Speaker Bureau Request Form

Speaker Bureau Request Form

Organization Name*

Event Name*

Event Description*

Please give as much detail as possible on your event.

How many expected attendees?*

Event Date

Event Time*

Event Location Name*

Event Location Address*

City

State

Zip / Postal Code

Who are you requesting to speak at your event?*

Select

Topic you would like Speaker to discuss:*

Allotted time for presentation*

Will there be a question and answer session?

Select or enter value

If so, how long?

Virtual speaking option if unable to be in person?*

Yes

No

Are any special guests/legislators attending?*

Yes

No

Who?

Will they be speaking?

Yes

No

Speaker Arrival Time

Type of Presentation*

Keynote

Panel

Fireside Chat

Other

Live Q&A*

Yes

No

Are you willing to share your attendee list?*

Are you willing to share the list of attendees & emails for this event?

Yes

No

Agenda*

Do you have a final or draft agenda to share?

Yes

No

Compensate*

Are you willing to compensate for travel costs?

Yes

No

Available AV?*

Yes

No

Marketing*

Do you have marketing collateral for the event promotion?

Yes

No

Additional Information

Please provide any additional information we may need to know.

Contact First Name*

Contact Last Name*

Preferred Contact Phone Number*

Preferred Contact Email Address*

Send me a copy of my responses

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