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REQUEST A SPEAKER
 
CONTACT INFORMATION  
Name of group or organization:
Contact person:
Address
City:
State:
Zip Code:
Telephone Number
Fax Number
Email Address
EVENT INFORMATION
Date:
Time:
Location (address):
Type of event (e.g. panel, training session, workshop, etc.):
About how many people do you expect to attend and who is your intended audience (e.g. members of the LGBT community, staff of your company or organization, etc.)?
Are any other organizations co-sponsoring this event with you? If so, who?
What is the deadline by which you will need us to respond?
SPEAKER INFORMATION
What topic(s) would you like us to speak about?
How long should the representative be prepared to speak?
Will other organizations or individuals be speaking? Yes No
If so, who?
How did you hear about the Pride Agenda and why have you asked us specifically to speak?
Anything else we should know in order to consider your request:
The Pride Agenda can usually cover the costs associated with speaking engagements, but we are a non-profit organization that relies primarily on donations. If necessary, would your group/organization be able to reimburse us for travel and other expenses? Yes No

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