1.What is the name of your organization?

2.Please write the name and title of the person requesting the talk.

3.How can we contact you? (email and/or phone number)

4.What is the title of your event?

5.What type of event is this? (e.g. a conference, public debate/panel discussion, cocktails/reception, fundraiser etc.)

6.What is the preferred topic for the presentation/remarks?

7.Is this a sponsored event?(If yes please indicate the sponsor.)

8.What is the date and time of the event?

9.What is the location of your event?

10.What type of room is the event taking place in? (e.g. boardroom, auditorium, conference hall etc.)

11.What is the event agenda/program?

12.What is the expected size of the audience?

13.Who will be in the audience?

14.How will the event be promoted? (e.g. will it be broadcasted or promoted via social media?)

15.What is the length/time of the presentation?

16.What is the A/V set-up in the room?

17.Would you like to pre-order copies of Danielle Martin’s book, Better Now: Six Big Ideas to Improve the Health of All Canadians from Penguin Random House (available January 10, 2017)? Pricing details can be provided upon request.

18.Are there other presenters/panelists, if yes, who are they?

19.Are there any other details you would like us to know about?