Speaker Request Question Title * 1. Requestor contact information Name Email Address Phone Number Question Title * 2. Event name Question Title * 3. Event or host organization website Question Title * 4. Event Start Date Date Date Question Title * 5. Event End Date Date Date Question Title * 6. Speaking start time Time Time AM/PM - AM PM Question Title * 7. Event type Lecture or Classroom Worship Service Conference Seminar "Ted Talk" Style/short speech On-Stage Interview Fundraiser Other (please specify) Question Title * 8. Event Location Venue Name Venue Address City/Town State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Question Title * 9. Event Description Question Title * 10. Presentation length of time (in minutes) Question Title * 11. Audience demographic Adult Youth Women Men Faith-based Professional Community Leaders Pastors College Students Ministry Leaders Philanthropists Other (please specify) Question Title * 12. Attendance (estimated total number of attendees) Question Title * 13. Other comments or special requests 100% of survey complete. Done
