Speaker Request Form

Thank you for your interest in having Dr. Maria Nemeth as speaker at your event. In order to help us facilitate your request, please complete and submit the following form (and any corresponding attachments) to [email protected] at least 2 weeks prior to the event, and allow 3-5 business days for decisions to be made.

If you have any questions or need help completing the Speaker Request Form, please call Dr. Maria Nemeth Office at +1 (916) 798-7066.

Part 1: Event Organizer

Name of Organization Submitting Request:

Event Sponsor(s):

For Profit/Not for Profit:

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

Part 2: Event Details

Event Name/Title:

Event Location/Title:

Event Date/Time:

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

Event Purpose/Goal:

Event Website:
(if applicable)

Part 3: Presentation/Speech Details

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?)

Part 4: Audience Details

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.)

Part 5: Additional Information

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.)

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