SPEAKER REQUEST FORM

COMPLETE THE FORM BELOW TO REQUEST

POC First name*

POC Last name*

POC Email*

POC Phone Number*

Organization Name (if applicable)*

Organization Website (if applicable)*

Organization Phone Number (if applicable)*

Organization Address (if applicable)*

Organization Email Address (if applicable)*

Who is this request for?*

Don

Ernestine

Both

Event Name*

Event Date*

Event Start Time*

Event End Time*

If multiple dates, list the start/end times for each date *

If multiple dates, will you need Don or Ernestine to be present at all dates?*

Yes

No

Optional

N/A

How many attendees are you expecting?*

How much time will Don or Ernestine be given to speak? (Hours/Minutes)*

What topic would you like Don or Ernestine to speak about?*

Are you willing to sign a speaker agreement?*

If no, please explain *

What is your desired outcome for the event and Don or Ernestine's talk?*

What is your anticipated honorarium budget for this event?*

Should travel be necessary, what accommodations will you provide?*

Accomodations will not be necessary

Flight

Car Rental

Car Rental - Gas

Hotel

Food

I'm unable to provide accommodations

Is there any other information you'd like Don and Ernestine to know?*

How did you find Don and Ernestine?*

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