* 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?

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