Speaker Request Form

Speaking Engagements

Contact Person *

Group Name *

Phone Number *

Date Requested

Time Requested

Length of Speaking Engagment

Physical Address

Brief Direction of the Size, Age, etc. of the Group

Desired Topics (check all that apply)

Volunteering Opportunities

Men's Division

Women and Children's Home

Gift in Kind Drive

Capital Campaign

Other

Do you have video capabilities?

Yes

If so, what format? (check all that apply)

VHS

DVD

Computer without Internet

Computer with Internet