NAME OF REQUESTING ORGANIZATION

    EVENT SPONSOR(S)

    Point of Contact

    Name:

    Title:

    Phone:

    Phone:

    Event Details

    Phone:

    WEBSITE

    DATE/TIME

    VENUE/ADDRESS

    OBJECTIVE

    EVENT TYPE (Dinner, Conference, etc.)

    REQUESTED TOPIC

    PRESENTATION FORMAT (On location or on air? Keynote, Round Table, Panel, etc.)

    EXPECTED DURATION

    Audience

    EXPECTED SIZE

    DESCRIBE (Briefly describe its make-up.)

    COST OF ATTENDANCE

    WILL MEDIA BE PRESENT?

    IF YES, WHICH MEDIA OUTLETS?

    Additional Details

    SPEAKER FEE 

    ATTIRE

    DINING ARRANGEMENTS

    TRAVEL EXPENSES

    LODGING ARRANGEMENTS

    TRANSPORTATION ARRANGEMENTS

    OTHER NOTES