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Speaking Engagement Request
Thank you for your interest in inviting Monique White speak at your event. Please take a moment to fill out this request form so we may facilitate your request. Provide as much detail as possible. Please allow 5-7 business days for a decision to be made.
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* Indicates required question
Name of Organization or Group
*
Your answer
Organization or Group Website
Your answer
Event Information
Date of Event
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MM
/
DD
/
YYYY
Event Time
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Time
:
AM
PM
Event Name
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Your answer
Venue
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Your answer
Location
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Indoors
Outside
Event Demographic: Who does the audience primarily consist of?
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Your answer
Number of Attendees (excluding presenters and staff)
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Your answer
Is the event open to the public?
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Yes
No
Maybe
Theme or topic. Please be as specific as possible
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Your answer
Type of appearance requested
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Keynote
Breakout Presentation
Panelist
Other:
If this is a panel discussion, please provide the names of others serving on the panel so a conflict check can be conducted
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Your answer
Will a meal be served during the presentation?
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Yes
No
Duration of speech
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Your answer
Will a LCD projector, screen, laptop, connectors, or wireless mouse be provided?
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All
LCD projector and screen
LCD projector, screen, laptop mouse only
No
Speaker Budget
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Your answer
Will expenses be covered for the speaker?
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Yes
No
Will media be present (TV, radio, print)? If so, who?
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Your answer
Requestor Contact Information
Contact Name
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Your answer
Contact Email
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Your answer
Telephone
*
Your answer
Mobile Number
*
Your answer
Fax Number
*
Your answer
Please provide any additional information that would be helpful in evaluating this request.
Your answer
Submit
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