Speaker Request Form

Priority Urgent Not Urgent Schedule Hold

Requested Speaker CEO Elmer Moore, Jr. Kim Plache, Deputy Director Jessica Boling, Asst. Deputy Director Other WHEDA staff

Other Speaker

Would you be willing to accept another speaker if the one requested cannot participate? Yes No

Speaker’s Role for the Event Keynote Moderator Panelist Welcome/Closing Remarks Award Presenter Media/Press Interview Meeting Webinar Reception Attend Only

Requesting Organization

Phone Number

Contact Name

Contact Email Address

Contact Title

Name Of Event

Event Date

Speaking Start Time

Speaking End Time

Deadline to receive speaker confirmation

Attire Formal Black Tie Business Casual Casual

Event Location

Event Description

Audience Composition

Audience Size 25 or less 25-50 50-100 More than 100

Focus of Talk

Length of Talk Attend Only 5 minutes 10 minutes 15 minutes 20 minutes 30 minutes 45 minutes 60 minutes

What type of speaking materials are needed?

When are the materials due?

Will the presentation be recorded? Yes No

Is media invited? Yes No

Will there be press coverage? Open to press Closed to press Inviting specific press

Associated Social Media

Any additional details we should know?