SCOSA Speaker's Bureau Presenter Request

This form needs to be completed if you are requesting a speaker or presenter for your company or organization. Once we receive your request you will be contacted by a SCOSA representative. Thank you.

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* 1. Contact Information

Name

Title

Company

Address

City

State

Zip

Website Address:

Email Address

Phone Number

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* 2. Please describe your current relationship and/or past involvement with SCOSA. If none, tell us how you heard about the Speaker's Bureau.

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* 3. Please tell us about your organization or business. Select all of the most appropriate descriptions.

For Profit

Not for Profit

AARP Chapter

Adult Day Care

Alumni Club or Organization

Assisted Living

Cultural Club or Organization

Educational Institution

Faith or Spiritual Organization

Older Adult Resource Center

Over 50 Living Community

Senior Center

Senior Nutrition Program

Social Service Organization

Other (please specify)

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* 4. Please describe the program you would like SCOSA to present for your organization. If you are unsure visit the SCOSA website event calendar for an example of SCOSA's current programs.

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* 5. Size of expected audience: how many participants would you expect for this presentation?

under 12

13 - 20

21 - 30

31 - 40

41 -50

51 - 70

71 - 100

over 100

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* 6. Location of presentation. Please provide the following information.

Company or Building Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Contact Name:

Email Address:

Phone Number:

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* 7. Please provide any additional information on the location of the proposed presentation including driving directions, access to public transportation, access to building and location of presentation room, etc.

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* 8. Please describe the meeting space and technology available for the presentation.

Participants seated in chairs arranged in rows

Participants seated at tables

Other meeting space available for private sessions with participants

Podium available for presenter

Table available for presenter

Microphone & speaker system available

Computer with internet connection available for presenter

Projector and screen with computer connection available for presenter

Other (please specify)

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* 9. Length of time alloted for the presentation including introduction, question and answer and conclusion.

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* 10. If you need the presentation for a specific date, please enter it below.

Date & Time Needed

Date

Time

AM/PM

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* 11. If you are flexible on the scheduling of this presentation please supply some choices for dates and times.

First Choice

Date

Time

AM/PM

Second Choice

Date

Time

AM/PM

Third Choice

Date

Time

AM/PM

Forth Choice

Date

Time

AM/PM

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* 12. Intended audience: please provide any information about your intended audience that will help us develop this program to meet your needs.

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* 13. Some of SCOSA"s presentations require a fee from the requester. What is your budgeted amount for this presentation. (Note: we will provide suggestions for alternatives that best match your budgeted amount).