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?

Topic you would like Speaker to discuss:

Allotted time for presentation

Will there be a question and answer session?

Virtual speaking option if unable to be in person?

Yes

Are any special guests/legislators attending?

Yes

Speaker Arrival Time

Type of Presentation

Keynote

Panel

Fireside Chat

Other

Live Q&A

Yes

Are you willing to share your attendee list?

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

Yes

Agenda

Do you have a final or draft agenda to share?

Yes

Compensate

Are you willing to compensate for travel costs?

Yes

Available AV?

Yes

Marketing

Do you have marketing collateral for the event promotion?

Yes

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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