Request a Speaker

Thank you for your interest in having a Visit Mobile speaker at your event. Please fill out the following form, for local events please submit at least 2 weeks prior to the event, for out of town engagements, please submit at least 6 weeks prior to the event. Please allow 3 to 5 days for a decision to be made.

AWAITING FORM

Event Organizer

Name of Organization:

Submitting Request:

Event Sponsor(s):

For Profit/Not for Profit

Coordinator/Point of Contact:

Title:

Email:

Office Phone:

Cell Phone:

Event Details

Event Name/Title:

Event Location:

Event Date/Time:

Event Type:

(conference, dinner, small group, etc.)

Event Purpose/Goal:

Event Website:

(if applicable)

Presentation/Speech Details Requested

Topic:

Presentation Format:

(keynote address, roundtable, panel, etc.)

Expected Duration:

(30 minutes, 1 hour, etc.)

Question and Answer

(Will the speech be followed by a Q&A session?)

Audience Details

Audience Description:

(Approximate size of audience. Also briefly describe its make-up and if membership is required to attend.)

Honorable Guests:

Media:

(Will media be invited? If so, will the event be open or closed press? Also describe and submit media list.)

Additional Information

Deadline for Acceptance:

Cost of Attendance:

(please include member and nonmember price, if applicable)

Offer of Payment/ Reimbursement:

(none, dining, lodging, travel, etc.)

Disclaimer/Release Form

(Please indicate whether or not the event sponsor will need the speaker to sign a disclaimer/release form.)

* Indicates a required field.