Requestor/Organizer

Full Name *

Phone *

Email *

Requesting Organization

Organization *

Website *

Description of Organization *

Event Information

Event Title *

Start Date *

Start Date: Start Time *

Start Date: End Time *

End Date *

End Date: Start Time *

End Date: End Time *

Event Registration Website *

Is there a registration fee for attendees? *

Yes

No

What is the registration fee? *

$

Is the event open to the public? *

Yes

No

Will the event be recorded? *

Yes

No

Is the event in-person, virtual or hybrid? *

In-person only

Virtual only

Hybrid (in-person and virtual)

Venue *

Address of Venue *

Description of Event *

Audience Size *

Primary Language of Expected Audience *

Audience Type *

Community Members

Government Agency

Professional

Student

Religious

Other

Other Audience Description:

Audience Knowledge of Topic *

Limited

Knowledgeable

Very Knowledgeable

Will there be an audience Q/A session? *

Yes

No

Is the agenda/schedule available for event? *

Yes

No

Upload a copy of the event agenda:

Will the media be present? *

Yes

No

Speaker Participation Details

Speaker Participation Format *

Keynote

Panel

Fireside Chat

Other

Workshop

Speaker Participation Date *

Speaker Participation Time *

Topic of Presentation *

Speaker Length of Participation *

Photo Needed? *

Yes

No

Photo Due Date *

Speaker Bio Needed? *

Yes

No

Bio Due Date *

Travel Information

Recommended Hotel Accommodations *

Nearest Airport to Venue *

On-Site Contact During Event

On-Site Contact Full Name *

On-Site Contact Phone Number *

On-Site Contact E-mail *

On-Site Contact Alternate Phone # *