Requesting Organization Information
Organization Leader
Organization Leader
Organization Contact Name *
Organization Contact Name
Organization Address
Organization Address
Contact Phone Number *
Contact Phone Number
http://
Event Information
Event Location
Event Location
Event Date (If Multiple Dates Enter To-Date) *
Event Date (If Multiple Dates Enter To-Date)
Event To-Date
Event To-Date
Event Time
Event Time
Type of Event *
Indicate multiple selections if necessary
Duration of Speaking Time
Is Rupert A. Hayles, Jr. the main speaker?
Is Maryann L. Hayles the main speaker?
Event Size
Attendee Demographics
indicate multiple selections, if necessary
Event Attire
indicate multiple selections, if necessary
Is photograph and bio of speaker required?
Are you able to provide travel expenses for one of our staff with the speaker?
As authors, the speaker(s) have material relevant to the engagement. Are you willing to make these materials prerequisite for the audience?
Internal Use Information
NO FURTHER ENTRY BELOW THIS LINE
Date of Request
Date of Request