Event Speaker Request

EVENT SPEAKER REQUEST FORM
Host Organization *
Website of Organization:
Proposed Dates & Times *
*CONTACT PERSON INFORMATION*
Contact Name (first,last) *
Contact Email *
Contact Phone: *
Contact Mailing Address: *
*EVENT INFORMATION*
Name/Title of Event *
Theme of Event: *
Preferred Topics: *
Time Required (Include speaking and autographing books) *
Estimated Number of People Attending *
Location (Include venue, street address, city & phone # *
Event Closing Time *
*EVENT PROMOTION*
Describe how your organization will promote the event: *
Check all appropriate boxes *	The event is open to the public. A fee will be charged
If a fee is charged, how much will the fee be?
Book Supply *	Organization will provide and sell Jane's books. Jane should bring her own supply of books.
Organization will provide assistance with book sales if needed. *	Yes No
DRIVING DIRECTIONS FROM MAJOR HIGHWAY *
*FEES & EXPENSES*
What amount does your group usually budget for a speaker presentation? *
Check all that apply:	We will reimburse mileage. We will reimburse travel expenses.
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