Training Request - CCMNT Speakers

Date *

Sponsor *

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

Speaker/Facilitator *

How did you hear about the speaker?

Virtual or In Person *

Training Topic *

Training Date(s)/ Times *

Please submit at least 3 dates

Training Duration *

Training Objectives *

Number of Expected Attendees *

Audience Profile *

Is this training open to the public? *

YES
NO

What online technology system will you be using?

Speaker Attire (mark one): *

Casual
Business Casual
Business
Academic Regalia

Training Budget *

Sponsor Contact Information

Sponsor Contact Name *

Title *

Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Signature

Name and Title of Individual Responsible for Signing Contract *

By signing below you acknowledge that this Speaker Booking is a FIRM offer. If Speaker accepts this offer, a binding contract will subsequently be formed. You represent that you have the requisite authority to make a FIRM offer. This firm offer form must be filled out and signed by someone with the requisite authority. THIS IS NOT A CONTRACT *

Signature

Date