Request A Speaker

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(*) Required

First Name*
Last Name*
Organization*
Email*
Phone* ex. 1234567890(No hyphens or spaces)
Event Name*
Event Date
Date ranges can be indicated in the notes box below on the bottom.
Event Address
Event Country*
Organization Hosting Event*
Event Type* National    International    Local
Electronic (Web, Internet, Distance Learning)
Presentation Type* Keynote    Panel    Other (Specify in Message field)
Audience Description*
(Check all that apply)		 Business/Professional    Military
Contractors    Government
Other (Specify in Message field)
Audience Size* Under 50    50-100    100+
Total Speech Time (in minutes)*
ex. 45 or 30-60 or 90 to 120, etc.
Confirmation Requested by Date
ex. Nov. 10, 2014 or Nov. 12-14, 2014 or October to November
Event Open to Press?* Yes    No
Travel Expenses Covered?* Yes    No
Topic*
Notes