Speaker Request Form

* denotes a required field.

Name of Event  *

 

Date/Time of Event*

 

Location*

 

Main Contact

Name*

 

Phone Number*

 

Email Address*

 

Alternate Contact

Name



Phone Number



Email Address



Event Details

Description of Event*

 

Sponsoring Department/School/Organization



Type of Speech*                                                                                                   No speech necessary, only presence requested
Welcoming remarks (3-5 min)
Introductory remarks (5-10 min)
Brief address (10-15 min)
Major address (30+min)
PowerPoint Presentation* 
Yes
No
Goal/What does the audience want to hear?*

 

Equipment provided at the location*                   
Lapel Microphone
Microphone
Lectern (preferred)
Projection
Computer

Will there be other speakers?
Yes
No
If yes, what is the speaking order?



Who will be introducing Dr. Green?



Would you like to receive Dr. Green’s bio for the introduction?
Yes
No
Attendance Estimate*

 

Former Students or Donors in audience?
Yes
No
Dean’s expenses (if any) to be charged to



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