Organization name:

Product, Service or Organization mission:

Describe the event:

Date:

Time:

Who is the Audience (ages, etc):

How many:

Venue:

Venue set-up/details:

Tell us about your speaker requirements:

  Keynote     Seminar     Course     Other:

Length of Presentation:

  Under 30 minutes       45 minutes   60 minutes   90 minutes                

   2 hours      1/2 day       full day       other:                      

 Budget range:

  Free   Under $1500 $1500-$3000   $3000-$5000   $5000-$7500

Other: $

(Some speakers will speak for free if it is an organization/charity or cause that is in alignment with their    beliefs and/or the event is free to attendees.)

Additional Expenses:  Some speakers will also require travel, hotel, meals, etc: Do you have a budget allotted for these expenses?yes  No  Explain:

What is the topic?

List additional if necessary:

What speaker (if known)?

Comments

:

Contact Information (required):

Name

:

Email Address:

Company Web:

Phone:

Fax:

Address:

City,State, Zip: