* 1. Date of Event

* 2. Time of event:

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

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

* 5. Length of speaking/presentation time:

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

* 7. Will Carmela be required to utilize PowerPoint?

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

Subject Matter

* 9. Is this CPCA/Healthcare related?

OR

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

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

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

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

* 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.

* 15. Your name:

* 16. Your organization:

* 17. Your title:

* 18. Your phone number:

* 19. Your Email:

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