Book a Speaker

Please submit this completed form to request further information on Speaking engagements. We will get back to you shortly.

Requesting Organization *

Description of Organization and Organization Mission *

Contact Name *

Contact Title

Contact Email *

Contact Phone *

Example: 555-555-5555

Type of Request *

Please note that fees for Speaker’s Bureau engagements vary depending on type of request.

Event Name

Event Description

Date of Event *

Include start time and finish time. Please indicate if request is for a multi-day event.

Other speakers at event (if applicable)

Event Location Address *

Address 2

Apt, Suite, Bldg. (optional)

City

Province

Is this event is part of a conference of symposium? If yes, please name:

Potential Audience Size *

Subject/Topic

Audience Type

How long is the presentation?

Additional Information

Speaker’s Bureau