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* 1. Date of Event

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* 2. Time of event:

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

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

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* 5. Length of speaking/presentation time:

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

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* 7. Will Carmela be required to utilize PowerPoint?

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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

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* 9. Is this CPCA/Healthcare related?

OR

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

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

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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?

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

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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.

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* 15. Your name:

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* 16. Your organization:

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* 17. Your title:

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* 18. Your phone number:

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* 19. Your Email:

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