Speakers Bureau Request & Confirmation Form

* indicates required information.

DATE REQUIRED:*
TIME to arrive:
TIME of presentation:
TIME for speech:
NAME OF COMPANY: *
Location of Presentation:
Name of ECC (Co-ordinator at Workplace): *
Phone #:		E-mail: *
Size of Audience:
Special Instructions:

Speaking to (ie. Training, Employee, KickOff, etc):

What Speakers have addressed this group in previous years?


United Way Rep (this person will intro presentation & field United Way questions):
Name:		Position:
Phone #:		E-mail address:

AGENCIES requested / ISSUES of interest:
1st choice:
2nd choice:
Requested by:		Phone #: