Request A Speaker
Presentation Date *
Presentation Date
This is the time that the speaker is expected to start their presentation.
If you are requesting more than one presentation, please provide times in the 'background' section of this form.
Please include room #, building #, name of boardroom, etc.
Wheelchair Accessible *
When should the speaker be on site.
When will the speaker be able to leave.
United Way Contact Information
United Way Rep *
United Way Rep
Mobile *
Site Contact Name *
Site Contact Name
Site Contact Phone *
Site Contact Phone
ECC Name *
ECC Name
Event Details
This information helps match the appropriate speaker to your account's audience.
Type of Event *
Please include any details that you feel will assist us in choosing the most appropriate speaker for your account.
Did the account indicate a topic / speaker preference? *
Campaign Theme/Presentation Topic (Optional)
What are best matches your account's interests?
Audience Profile