Speakers Bureau Request Form

Meeting Contact

First Name Last Name Requesting Organization Sponsoring Organization Address 1 Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 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

Meeting Information

Type of Meeting Meeting Date

Leave blank if currently unknown.

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 Location Address 1 Meeting Location Address 2 Meeting Attire Business Business Casual Casual A/V Equipment Available Recommended Lodging Name Recommended Lodging Address Recommended Lodging Phone Closest Airport Recommended Ground Transportation Additional Information / Comments

Billing Contact Info

Billing First Name Billing Last Name Billing Title Billing Organization Billing Address 1 Billing Address 2 Billing City Billing State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Billing Zip Code Billing Phone Billing Email Billing Fax