Request a NASA Speaker

Indicate Equipment Available

Lavaliere or Lapel Microphone

LCD Projector

DVD Player

Room can be darkened

Public Address System

Computer with Presentation Software

To request a NASA speaker, please fill out the request form below and provide as much information as possible about the event. Note: This form can not be used to request an astronaut appearance. View more information on astronaut appearances.

* Indicates a required field
Contact information of person requesting a speaker:
*	First Name:
*	Last Name:
*	Primary Phone Number:			Ext.:
	Alternate Phone:			Ext.:
*	E-Mail Address:
*	Country:
*	Address:
*	City:		*	State:	*	Zip Code:
		City, State, and Zip Code are only required if the country is United States

Event Name and Address:
*	Event Name:
*	Sponsoring Organization:			Website:
*	Event Date: (mm/dd/yyyy)
*	Speaker Start Time: (hh:mm)	(local time to the event)
	Event address same as contact address

*	Event Country:
*	Event Address:
*	Event City:		*	State:	*	Zip Code:
		City, State, and Zip Code are only required if the country is United States
	Building or Room:

Other Event Information:
	Event Type:		Presentation Type:
	Topic Requested (if known):
	Speaker Requested (if known):
*	Expected Audience Size:	(numbers only)
*	Audience Description:
	Number of Presentations:
	Total Time Allotted (in minutes):		Q&A included?
	Confirmation Requested By: (mm/dd/yyyy)
	Other Scheduled Speakers:

	Event Open to the Press?						If yes, please provide details:
	Event to be Broadcast?						If yes, please provide details:
	Speech to be Taped?
	Speaker bio needed?
	Speaker photo needed?

Any other information that may help to clarify your request:


	I agree to the terms and conditions as outlined below: No person for reason of race, color, sex, religion or national origin, will be excluded from or segregated within membership in sponsoring organization, attendance at event or any of the facilities housing this event. The NASA speaker will not be participating, or appear to be participating, in fundraising, sponsorship, endorsement or financial assistance for the benefit of the requesting organization, the event, or any product or program.

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	10.29.2008