CE - Speaker Request Form

First Name *

Last Name *

Phone Number *

Email Address *

What is the name of your group or organization? *

What would you like us to speak about? *

Do you require more than one speaker? If so, how many do you need? *

No

Yes Yes

Would you like to request a specific TRM staff member to speak? *

No

Yes Yes

When would you like us to speak? * +

What time would you like us to speak? *

How many people will we be speaking to (approximately)? *

Who is our audience? *

Where would you like us to speak? *

What A/V equipment will be available for us to use (i.e. number of microphones, projectors, speakers, etc.)? *

Any thing else we might need? *