Career Development

Request for Speaker Form

January 11, 2017   /
Elaine M. Hinzey, RD, LDN

Name of requesting group: __________________________________________

Date of request: ____________

Contact person: __________________ Phone: __________________ Email:__________

Alternative contact person: _______________Phone: _____________Email:_________

Full address of speech location: _____________________________________________

Date and time of speech:_____________________________

Speech topic requested: ________________________________________________________________________

Length of presentation requested: ___________________________________________

Audience profile and size: __________________________________________________

Will a confirmation letter with driving direction be provided? ____________________

Will the engagement be broadcast or recorded? _______________________________

Will newspaper, television, or other press be present? __________________________

What is the deadline for accepting invitation? _________________________________

Which of the following will be available:
☐ AV equipment
☐ Tables #_________
☐ Wireless microphone
☐ Large projection screen
☐ Heavy duty extension cord
☐ Power strip
☐ Podium
☐ Reliable Internet access
☐ Whiteboard
☐ Easel

Is a door prize requested? __________________________________________________

Are special favors requested?_______________________________________________

Are special decorations or table covers necessary? _____________________________

Will a meal be provided for the speaker?_____________________________________