What is the name of your organization?

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* 1. What is the name of your organization?

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

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

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

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

What is the title of your event?

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* 4. What is the title of your event?

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

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

What is the preferred topic for the presentation/remarks?

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

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

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

What is the date and time of the event?

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

What is the location of your event?

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* 9. What is the location of your event?

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

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

What is the event agenda/program?

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* 11. What is the event agenda/program?

What is the expected size of the audience?

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* 12. What is the expected size of the audience?

Who will be in the audience?

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* 13. Who will be in the audience?

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

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

What is the length/time of the presentation?

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

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

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

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.

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* 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.

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

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

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

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

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