Speaking Engagement Form

Speaking Engagement Request

Thank you for your interest in working with me! Please provide me with some information for your event below so that I can better serve you.

Name of Your Organization

Name of Event

Event Date

Event Start Time

Event End Time

Is this a paid request?

To help me plan, please tell me the theme and some information about your event.

What topic would you like me to speak on?

Requested Presentation Length

In-person or virtual event?

Projector and screen available?

If in-person, what is the address for the event?

Number in Attendance

What three (3) main issues would you want me to address for your audience?

Name of Contact Person

Phone Number

Any additional information regarding your request you would like me to know?