Name of Organization

Topic or Speaker Requested

Date of Event (if no specific date yet, what month or day of the week?)

Location/Directions for Event

Time of Event

Approximate length of time you want speaker to talk

Brief description of event (i.e., monthly club meeting, conference, PTA training session,etc.)

Audience size

Do you have a budget for a speaker honorarium?
Yes
No

If yes, what is your budget?

Contact person's name

Contact person's daytime phone

Contact person's evening phone

E-mail address