Organization name:

Contact person:

Address:

Phone:

Fax:

E-mail:

First choice:

Second choice:

Third choice:

Event for which speaker is needed:

Date of Event:

Time:

Length of presentation:

Number of people expected to attend:

Demographic information (Please describe the people who will attend—men or women, ages, etc.):

Event location/address:

Driving Directions:

What audiovisual resources are available at this facility?

Does your audience have any special needs?

Please provide any additional information that might help us to determine the best person to work with you.