CEO Speaker Request Form Question Title * 1. Date of Event Question Title * 2. Time of event: Question Title * 3. Location of event (City/State): Question Title * 4. Audience (who and # of expected attendees): Question Title * 5. Length of speaking/presentation time: Question Title * 6. Format of request (Welcome Address; Keynote Address; Panelist, etc.): Question Title * 7. Will Carmela be required to utilize PowerPoint? Yes No Question Title * 8. If this is a panel, who are the other expected/anticipated co-panelists?(please note names, organizations and titles) Subject Matter Question Title * 9. Is this CPCA/Healthcare related? Yes No OR Question Title * 10. Is this Castellano Family Foundation/Philanthropy related? Yes No Question Title * 11. What is the topic you’d like Carmela to speak to? Please be as specific as possible. Question Title * 12. Please indicate if there is anything else you would like Carmela to highlight or mention as part of the requested remarks? Question Title * 13. Does your organization plan to cover the speakers’ related travel costs to attend the event? Yes No Question Title * 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. Question Title * 15. Your name: Question Title * 16. Your organization: Question Title * 17. Your title: Question Title * 18. Your phone number: Question Title * 19. Your Email: Submit