Speaking Request Form

Questions? Call 704-968-2253

Event Details

Name of Workshop, Seminar, or Speaking Event

Sponsoring Organization

Event Theme

Name of the contact person

Phone

Event Date (Fixed or Tentative)

Month

Day

Year

Event Location (City/State)

Expected Number of Attendees

Median Age of Attendees

Content/Topics to Be Covered

Speaking Logistics

Speaking Time Per Session

Total Sessions Required

Specific Meeting Times

Budget & Expenses

Budget Allocated for Speaker

Will travel & accommodation be covered?

Yes

Hotel Name / Address (if overnight stay required)

Hotel Phone Number

Who will transport to/from airport?

Please enter name above

Please provide the work and home phone numbers of the person above who will be transporting

Any Special needs your organization may have when it comes to logistics.

Person Completing Form

Name of person completing this form

Phone Number

Position/Title

Additional Notes

Cancellation Policy: If canceled after confirmation, a 25% cancellation fee and reimbursement for any non-refundable expenses (including airfare) will apply.