* Required information

* Event Name:

Event Date: (mm/dd/yyyy)

If your event date is not confirmed yet please leave this field blank and provide your projected or desired dates in the "Additional Information" field.

Event Website:

* Sponsoring Organization:

Sponsor Mailing Address:

City:

State/Province:

Zip Code/Postal Code:

Country:

Website:

* Contact First Name:

* Contact Last Name:

* E-mail Address:

* Daytime Telephone:

* Event Description:

* Intended Audience:

* Audience Size:
Select one < 50 50-150 151-500 > 500

Will the event be recorded or broadcast?:
Select one Yes No Maybe

Length of Presentation:

* Event Venue and Location:

Additional Expectations of Speaker:

* Budget for Speaker Honorarium:
Don't know yet Less than $1,000 $1,000 - 3,000 $4,000 - 6,000 $7,000 - 10,000 More than $10,000 No budget

Travel expenses are in addition to the honorarium.

* Budget for Travel Expenses:
Select one Don't know yet $500 - 1,000 $1,000 - 1,500 More than $1,500 No travel budget

Will there be other speakers?:
(Check for "Yes")

If yes, please provide names of the other speakers and if they have been "confirmed" or "invited" in the box below.

Who are the other speakers?:

Additional Information:

If you have already spoken with someone at the Guild or Institute about your speaker request, please include their name here, if known.