Speaking Request Form

Questions call 570-856-5178

Name of Workshop, Seminar, or Speaking Event

Sponsoring Group

Name of Contact Person

Name

Phone Number

Email Address

Mailing Address

Address Line 2

City

State/Province/Region

ZiP/Postal Code

State/Province/Region

ZiP/Postal Code

Country

Meeting Location

Is meeting date fixed of tentative?

Specific Content to be covered?

Specific meeting times

What is the theme for your event?

Actual speaking time during each meeting

Are there other speakers? If so, who?

Number of attendees expected

Median age of attendees

Honorarium (please write a specific U.S. dollar amount)

Will honorarium be given in advance?

The final day of meetings?

Special arrangements needed?

Hotel Name

Hotel Address

Street Address

Address Line 2

City

13 + 2 =