AMPLIFY Clearwater Speaker Request Form

Question Title

1. Organization Name (Required.)

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2. Event Name (Required.)

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3. Event Description (Required.)

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4. Event Date (Required.)

Date of Event

Date

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5. Event Time (Required.)

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6. Location of event including address (Required.)

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7. What is the expected audience size? (Required.)

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8. What is the format of the speaking engagement? (Required.)

Keynote

Panel Discussion

Fireside Chat

Workshop

Seminar

Breakout

Other

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9. What topics would you like the speaker to cover? (Select all that apply) (Required.)

Marketing

Leadership

Innovation

Community Engagement

Economic Development

Other (please specify)

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10. What staff member are you requesting? (Required.)

Amanda Payne - President & CEO

Jeni Torello - EVP, Operations

Joe Lugo - Director, Foundation & Entrepreneurial Services

Meegan Massey - Manager, Events

Brianna Saraceno - Manager, Marketing

Other (please specify)

AMPLIFY Clearwater Speaker Request Form

Question Title

1. Organization Name (Required.)

Question Title

2. Event Name (Required.)

Question Title

3. Event Description (Required.)

Question Title

4. Event Date (Required.)

Question Title

5. Event Time (Required.)

Question Title

6. Location of event including address (Required.)

Question Title

7. What is the expected audience size? (Required.)

Question Title

8. What is the format of the speaking engagement? (Required.)

Question Title

9. What topics would you like the speaker to cover? (Select all that apply) (Required.)

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10. What staff member are you requesting? (Required.)

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11. Contact Full Name (Required.)

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12. Preferred Email Address (Required.)

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13. Preferred Contact Number (Required.)

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14. Please provide any additional information or special requests.

AMPLIFY Clearwater Speaker Request Form

Question Title

* 1. Organization Name (Required.)

Question Title

* 2. Event Name (Required.)

Question Title

* 3. Event Description (Required.)

Question Title

* 4. Event Date (Required.)

Question Title

* 5. Event Time (Required.)

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* 6. Location of event including address (Required.)

Question Title

* 7. What is the expected audience size? (Required.)

Question Title

* 8. What is the format of the speaking engagement? (Required.)

Question Title

* 9. What topics would you like the speaker to cover? (Select all that apply) (Required.)

Question Title

* 10. What staff member are you requesting? (Required.)

Question Title

* 11. Contact Full Name (Required.)

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* 12. Preferred Email Address (Required.)

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* 13. Preferred Contact Number (Required.)

Question Title

* 14. Please provide any additional information or special requests.

1. Organization Name (Required.)

2. Event Name (Required.)

3. Event Description (Required.)

4. Event Date (Required.)

5. Event Time (Required.)

6. Location of event including address (Required.)

7. What is the expected audience size? (Required.)

8. What is the format of the speaking engagement? (Required.)

9. What topics would you like the speaker to cover? (Select all that apply) (Required.)

10. What staff member are you requesting? (Required.)

11. Contact Full Name (Required.)

12. Preferred Email Address (Required.)

13. Preferred Contact Number (Required.)

14. Please provide any additional information or special requests.