Name of Organization Submitting Request:

Event Sponsor(s):

For Profit/Not for Profit:

Coordinator/Point of Contact:(Name, title, email, office phone, cellphone)

Event Name/Title:

Event Location/Title:

Event Date/Time:

Event Type:(conference, dinner, small group, etc.)

Event Purpose/Goal:

Event Website:(if applicable)

Requested Topic:

Presentation Format:(keynote address, roundtable, panel, etc.)

Expected Duration:(30 minutes, 1 hour, etc.)

Question and Answer:(Will the speech 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 Guests:(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 non-member price, if applicable)

Offer of Payment/Reimbursement:(dining, lodging, travel, etc.)

Disclaimer/Release Form:(Please indicate whether or not the sponsor will need that speaker to sign a disclaimer/release form.)