Speaker Request

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* 1. Requestor contact information

Name

Email Address

Phone Number

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* 2. Event name

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* 3. Event or host organization website

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* 4. Event Start Date

Date

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* 5. Event End Date

Date

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* 6. Speaking start time

Time

AM/PM

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* 7. Event type

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* 8. Event Location

Venue Name

Venue Address

City/Town

State

ZIP/Postal Code

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* 9. Event Description

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* 10. Presentation length of time (in minutes)

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* 11. Audience demographic

Adult

Youth

Women

Men

Faith-based

Professional

Community Leaders

Pastors

College Students

Ministry Leaders

Philanthropists

Other (please specify)

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* 12. Attendance (estimated total number of attendees)

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* 13. Other comments or special requests

100% of survey complete.