Booking Request Form

Please complete the form below

Please submit speaking requests at least 2 weeks prior to the event. Please allow 3-5 business days for a decision to be made.

Name

First Name

Last Name

Name of Organization Submitting Request

Event Sponsor(s)

Subject

Message

Type

Type of Event

Event Name

Event Location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Event Date

YYYY

Event Time

Hour

Minute

Second

Event Type

(conference, dinner, small group, television, radio, etc.)

Event Purpose/Goal

Event Website

(if applicable)

http://

Requested Topic

Presentation Format

(keynote address, roundtable, panel, etc.)

Expected Duration

(30 minutes, 1 hour, etc.)

Question and Answer

(Will the speech/appearance be followed by a Q&A session?)

Audience

(Approximate size of audience. Also briefly describe its make-up and if membership is required to attend.)

Honorable Guest

(List names and titles of members of Congress, CEOs, or other VIPs participating in, or attending the event.)

Media

(Will media be invited? If so, will the event be open or closed press? Also describe and submit media list.)

Deadline for Acceptance

Cost of Attendance

(please include member and nonmember price, if applicable)

Offer of Payment/Reimbursement

(honorarium, none, dining, lodging, travel, etc.)

Disclaimer/Release Form

(Please indicate whether or not the event sponsor will need the speaker to sign a disclaimer/release form.)

Booking Request Form

Please complete the form below

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