Speaker Request Form Name of your organization or association Name of contact person * First Name Last Name Title of contact person * Office Phone * (###) ### #### Cell Phone (###) ### #### Email * Please provide a brief description of the event for which you are seeking a speaker * Date of Event MM DD YYYY Time of Event Hour Minute Second AM PM How long is the event? Anticipated start and stop time of speaking portion Is this event in person or virtual? * In Person Virtual Name of event location or web address * Address of event location Address 1 Address 2 City State/Province Zip/Postal Code Country Please provide a brief description of your audience * Anticipated number of audience participants * What topic(s) do you have in mind? What is your budget or stipend for this event? * What else would be helpful for Suzanne to know prior to contacting you? Thank you! I will be in touch with you soon!