Speakers Bureau

Today’s date:

Name of company or organization:

Your Name (required)

Your Phone:

Your Email (required)

Will you be the contact person?
YesNo

If “no,” please provide contact person’s name:

Type of event (e.g., conference, seminar, luncheon):

Event name (if applicable):

Desired speaker topic:

Anticipated audience (e.g., academic, health care professionals, consumers):

Estimated audience size:

Desired length of speaker presentation:

Date and time of presentation:

Location of presentation (include specifics like street address, floor number or room name, etc):

Parking instructions for speaker:

Can you pay travel expenses if necessary?
YesNo

Can you pay honorarium if necessary?
YesNo

If “yes,” amount of honorarium: