SPEAKER/TOPIC
REQUEST

Please provide information for a single topic or speaker request on this page. Use additional copies of this page for additional presentation requests.

ASSOCIATION CONTACT:
ASSOCIATION NAME: 	
EVENT DATES/LOCATION 	
ASSOCIATION MEETING PLANNER CONTACT: 	
PHONE: 	
EMAIL: 	

PRESENTATION/EVENT DESCRIPTION:
TYPE: 	___ Keynote	___ Panel	___ Breakout Session 	___ Pre-Convention
	___ Other (Describe) 	
SUBJECT REQUESTED: 	
DATE/TIME DESIRED: 	
NUMBER OF ATTENDEES EXPECTED FOR THIS EVENT: 	
SPEAKING BUDGET FOR THIS EVENT: 	
DO YOU HAVE ANY SPECIFIC SPEAKERS IN MIND FOR THIS EVENT? 	
PLEASE INDICATE THE RELATIVE IMPORTANCE OF THE CRITERIA USED IN SELECTING PRESENTERS FOR THIS EVENT
Use a scale of 1-10: 1 = “Not at All Important”; 10 = “Sole Reason for Choosing”
Subject Matter Expertise: 		
Speaker Credentials: 		
Humor: 		
Speaker Energy/Dynamics: 		
Prior Experience: 		
Referral: