* 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:


*Company


*Address


*City


*State/Province


*Zip


*Country


Website


*First Name


*Last Name


Title


*Email


*Phone


*Event Venue:


Event Description:


Intended Audience:


Audience Size:
--None-- < 50 50-150 151-500 > 500

Will the event be recorded or broadcast?:
--None-- Yes No Maybe

Length of Presentation:


Additional Expectations of Speaker:


*Budget for an Honorarium:
--None-- No Budget < $1,000 $1,000-$3,000 $3,001-$6,000 $6,001-$10,000 > $10,000

Travel expenses are in addition to honrarium.

*Budget for Travel Expenses:
--None-- No travel budget $500 - 1,000 $1,000 - 1,500 More than $1,500 Don't know yet

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

If YES, please provide names of 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.