Date of Event

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* 1. Date of Event

Time of event:

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* 2. Time of event:

Location of event (City/State):

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* 3. Location of event (City/State):

Audience (who and # of expected attendees):

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* 4. Audience (who and # of expected attendees):

Length of speaking/presentation time:

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* 5. Length of speaking/presentation time:

Format of request (Welcome Address; Keynote Address; Panelist, etc.):

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* 6. Format of request (Welcome Address; Keynote Address; Panelist, etc.):

Will Carmela be required to utilize PowerPoint?

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* 7. Will Carmela be required to utilize PowerPoint?

If this is a panel, who are the other expected/anticipated co-panelists?
(please note names, organizations and titles)

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* 8. If this is a panel, who are the other expected/anticipated co-panelists?
(please note names, organizations and titles)

Subject Matter
Is this CPCA/Healthcare related?

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* 9. Is this CPCA/Healthcare related?

OR
Is this Castellano Family Foundation/Philanthropy related?

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* 10. Is this Castellano Family Foundation/Philanthropy related?

What is the topic you’d like Carmela to speak to? Please be as specific as possible.

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* 11. What is the topic you’d like Carmela to speak to? Please be as specific as possible.

Please indicate if there is anything else you would like Carmela to highlight or mention as part of the requested remarks?

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* 12. Please indicate if there is anything else you would like Carmela to highlight or mention as part of the requested remarks?

Does your organization plan to cover the speakers’ related travel costs to attend the event?

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* 13. Does your organization plan to cover the speakers’ related travel costs to attend the event?

Is there a maximum reimbursement amount? If so, what is the maximum reimbursement allowed?

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* 14. Is there a maximum reimbursement amount? If so, what is the maximum reimbursement allowed?

Speaker note: Carmela prefers a podium for all speaking engagements to audiences larger than 10 people.
Your name:

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* 15. Your name:

Your organization:

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* 16. Your organization:

Your title:

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* 17. Your title:

Your phone number:

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* 18. Your phone number:

Your Email:

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* 19. Your Email:

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