Speaker Invitation Form - CCMNT Speakers

Sponsor *

(Provide the name of host organization, street address, city state, zip code)

Sponsor/ Event Website *

Speaker *

Are you considering other speakers for this same opportunity *

How did you hear about the speaker?

Virtual or In-Person Event *

Event Date(s) *

Event Description (including other invited and confirmed guests) *

Please include a description of the event

Proposed Speaker Schedule *

Please include any pertinent information related to the time and actives of the event including all duties of the speaker during this engagement (example: Lecture, class visit, lunch with sponsors)

Event Time(s) (including time zone) *

Event Location *

Please list the building and address of the in-person event

Type of Speaking Engagement *

Select all that apply to the engagement

Time alloted for speaking engagement *

Please list the exact time frame or number of minutes the speaker will be expected to prepare for. (Example: 45 min lecture)

Length of Q&A *

Are you hoping to have a planning call with the speaker?

Please note that not all speakers have capacity for planning calls

Please describe your organization's COVID-19 Protocols

Closest Airport to the Event Location and Distance Between Venue and Airport

Please include name of airport, distance from the event location, and travel time to the event location

Event Platform

Do you plan to have a technology run-through?

Please note that some speakers will not attend tech calls.

Instructions for Event Platform

Amount Offered for Speaker Fee *

Topic *

Audience Profile *

Number of Expected Attendees *

Public Event *

YES
NO

Anticipated Book Sales

If Applicable

Speaker Attire (mark one): *

Casual
Business Casual
Business
Academic Regalia

Sponsor Contact Information

Sponsor Contact Name *

Title *

Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Signature

Name, Title and Email Address of Individual Responsible for Signing Contract *

A formal contract will be created if the speaker accepts the invitation. This is NOT a contract *

Signature

Submission Date *

Date