Speaker Request Form Speaking requests will be considered on a case-by-case basis. Member organizations will be given priority with our staff's very busy schedules. Once submitted, please allow 5 business days for a response. Question Title * 1. Your name (Required.) Question Title * 2. Your email (Required.) Question Title * 3. Organization name (Required.) Question Title * 4. Mission of organization (Required.) Question Title * 5. Event name and brief description (Required.) Question Title * 6. Event date and time (Required.) Date / Time Date Time AM/PM - AM PM Question Title * 7. Event location (Required.) Question Title * 8. Who are you requesting to speak? (Required.) Mary Kane Andrew Griffin Whitney Harmel Any available speaker Other (please specify) Question Title * 9. Exact time of speech and requested speech length (Required.) Question Title * 10. Desired speech topics (Required.) Question Title * 11. Audience size and profile (Required.) Question Title * 12. Will their be questions from the audience? (Required.) Yes No Other (please specify) Question Title * 13. Will media be present? (Required.) Yes No Done