Speaker Request Form - Care to Change

What type of organization is the event for? (Corporate, political, non-profit/church, other?)(Required)

What is the name of the event (if applicable)? What type of event is it?"(Required)

What are the dates/times for the event?"(Required)

What is the address and location (including building and room number) of the event?(Required)

Do you have a preferred speaking topic, or would it be the speaker's choice?(Required)

How much time would you like us to speak, and would you desire time for Q & A with the audience(s) or not?(Required)

What is the estimated size and demographics of your group?(Required)

Will there be any other speakers at the event, and if so, who are they?(Required)

What is your budgeted honorarium/speaking fee for this event?(Required)

Who is the primary Point of Contact for this event? Please include name, title (if necessary), phone number, and email address.(Required)

What other information, if any, would be helpful as we consider this request?(Required)

Name

This field is for validation purposes and should be left unchanged.