Speakers Bureau Request Form

Organization Information

First Name Last Name Your Title Your Credentials Requesting Organization Sponsoring Organization Address 1 Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Organization Zip Code Phone Contact’s Phone on Day of Meeting Email Requesting Organization’s Website URL

Meeting Information

Type of Meeting Meeting Date

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Presentation Time

Presentation time must be provided prior to confirming.

Time Zone (for webinars only) Eastern Central Mountain Pacific Requested Topic Requested Speaker Length of Presentation 05 to 1 hour 1 to 2 hours 2 to 3 hours Audience Size Audience Composition Meeting Venue Name Meeting Venue Address Meeting Attire Business Business Casual Casual A/V Equipment Available

Travel Information

Recommended Lodging Name Recommended Lodging Address Recommended Lodging Phone Closest Airport Recommended Ground Transportation Additional Information / Comments