Contact Information of Person Requesting Speaker

Your name: *

Your title:

Your organization:

Your address: *

Please include your street, city, state and ZIP code.

Your county: *

Primary phone: *
Please include your extension if any.

Alternate phone:
Please include your extension if any.

Fax:

E-mail address: *

Peferred method of commuication: *
 Phone    Fax    E-mail  

Event Name, Date and Address

Event name: *

Sponsoring organization: *

Sponsor or event website:

Preferred Date 1 (m/d/y): *

Preferred Date 2 (m/d/y):

Preferred Date 3 (m/d/y):

Preferred Time 1: *

Preferred Time 2:

Preferred Time 3:

Requested length: *

Is the event address the same as the contact address? *
 Yes    No  

Event Address:

Event County:

Building or room:

Additional Event Information

Event type: *
Keynote   Panel   Table   Presentation with Q&A   Consultation with Individuals   Other  

Topic to speak on: *
Bankruptcy BasicsDating Violence and Healthy RelationshipsDecisions ClassesDomestic Violence and Stalking and Sexually Oriented Offenses BasicsFinancial Information and Legal EducationForeclosure FundamentalsIntroduction to Legal Aid ServicesLandlord - Tenant LawLitigation Boot CampLow Income Taxpayer InformationSenior Legal ToolkitWhat is Legal Aid and How to Access ServicesOther (please specify below) Topic Descriptions

If other, please specify below:

Expected audience size: *

Audience composition: *

For example, students, seniors, low income.

Number of presentations: *

Total time allotted: *

Is a question and answer time included?
 Yes    No  

Confirmation requested by (m/d/y): *

Other scheduled speakers:

Is the event open to the press?  Yes    No  

If yes, please provide details:

Will the event be broadcast?  Yes    No  

If yes, please provide details:

Do you need a speaker bio?  Yes    No  

Do you need a speaker photo?  Yes    No  

Available Equipment

What equipment will be available for use at the event site?
 Microphone LCD Projector Projector Screen Computer with Microsoft PowerPoint

Additional Information

Please provide any additional information: