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Speakers Bureau Program for 2005-2006  

 

Online Application form | Publicizing Your Event | Reporting Forms

Speakers Bureau Program Application Form

Please be sure to read "Hosting a Speakers Bureau Presentation" before requesting a speaker.

  Sponsor Information
  Is your organization nonprofit? Yes

No

 
  Organization Name:  
 
  Address:  
 
  City: State: Zip:
 
  Coordinator's name:  
 
  Program Coordinator's Mailing Address (if different from organization address above)  
 
  Daytime Telephone:  
 
  E-mail Address:  
 
  Speaker Information
  Requested Speaker's Name:  
 
  Topic of Presentation:  
    Many speakers offer presentations on more than one topic. Please select and copy the name of the requested program from the applicable page, then paste it in the field above.
 
  Program Information
  Program Date:  
    Note: date must be at least 8 weeks after date of request.
     
  Program Time:  
       
  Alternate date (if speaker is not available):  
       
  Location and Address of Program:  
       
  Congressional District for Program Location:  
       
  State Legislative District for Program Location:  
    If you do not know which district the location is in, click here for lookup information.
     
  County for Program Location:  
       
  Is the site handicapped accessible? Yes

No

 
  Will this program be free and open to the public? Yes

No

 
  How do you plan to publicize this program? (Check all that apply)
  Organizational newsletter or mailings to members: Yes

No

 

  Notices to newspapers and radio stations: Yes

No

 
  Other (Please describe):  
       
  Estimated Audience:  
       
  Type of audience/grade level:  
       
  Is audio/visual equipment available for the speaker? Yes

No

 
  Do you plan to videotape the program? Yes

No

 
  How did you learn about the Speakers Bureau?  
 
  I have read and understand my responsibilities and those of my organization.
  Name:  
 
  Date: