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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:	Select a Presenter Ali Omar H.Barry BillBelasco WarrenBelasco WarrenBerkowitz Edward D.Bond Chrystelle T.Briley-Strand GwendolynBuccino Daniel L.Callum Agnes KaneCamp CharlesCasway JerroldClemens Thomas G.Coleman Jeffrey LamarCrane Christopher E.Cripps ThomasDean David M.Diggs LouisDixon MichaelDrew Anne-MarieDurr KennethErnst HowardFeldstein AlbertFord MartinFranch MichaelFrantzich Stephen E.Gbotokuma Zekeh S.Gerdes Mary ReginaldGibb James G.Ginsberg RobertGlaser Michael S.Goodman Melvin A.Grimmette BillHam Debra NewmanHarley SharonHenderson Lenneal J.Henning BrianHildebrand David M.Hill, Jr. Walter B.Hollis Burney J.Jung Mary AnnJung (Julia Child) Mary AnnKachur RobertKeely Karen A.King TimKrondorfer BjornLangley Susan B. M.Lee Hugh MingLeonard Walter J.Levy PeterMcCune JeffreyMcWilliams MarkMiller Henry M.Miller Paul B.Norman JoanOkonowicz EdOrser EdwardPeterson Carla L.Peterson Carrol D.Pineo RonnPower GarrettRamsey Priscilla R.Reber Patricia BixlerSchaumburg Wayne R.Scheper George L.Sears RussSims-Wood JanetSmith Judith R.Smith DavidTerry David TaftThomas Kara RogersThompson BruceTwitty MichaelVann Paul LawrenceVivian Margaret Enloevon Kellenbach KatharinaWalsh Joseph J.Wapner PaulWebster ColleenWebster Colleen M.Wennersten John R.Williams Glenn F.Williams-Forson PsycheWilski-Strong Marianne
	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: