Speaker Request Form

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Thank you for your interest in having me at your event. In order to help me facilitate your request, please complete and submit the following form (and any corresponding attachments) to speakersbureau@cutlassleadership.com at least 2 weeks prior to the event, and allow 3-5 business days for decisions to be made. Speaking fees vary based on nature of request.

Email *

Part 1: Event Organizer

Name of Organization Submitting Request: *

Event Sponsor(s): *

For Profit/Not for Profit: *

For Profit

Not For Profit

Coordinator/Point of Contact: (Name, title, email, office phone, cellphone) *

Part 2: Event Details

Event Name/Title: *

Event Location: *

Event Date *

YYYY

Event Time *

Time

Event Type: (conference, dinner, small group, etc.) *

Event Purpose/Goal: *

Event Website: (if applicable) *

Part 3: 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?) *

Yes

Part 4: Audience Details

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

Honorable Guests: (List names and titles of members of Congress, CEOs, or other VIPs participating in, or attending the event.) *

Media: (Will media be invited? If so, will the event be open or closed press?) *

Yes

Media: (describe and submit media list.) *

Part 5: Additional Information

Deadline for Acceptance: *

YYYY

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.) *

Yes

Please submit speaking requests at least 2 weeks prior to the event.

Please allow 3-5 business days for a decision to be made.

Please submit any corresponding attachments to speakersbureau@cutlassleadership.com

A copy of your responses will be emailed to the address you provided.

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