Working Well NJ
Speaker's Bureau Program Speaker request information
   
I. Sponsoring organization(s):
  Person to contact relative to this request:
  * First Name:
  * Last Name:
  * Telephone Number: ( )  -         Ext:
  * Fax Number: ( )  -
  * Email Address:
  Address
  * Street Address:
  Suite/P.O.Box:
  * City:
  * State:
* Zip Code+4:  -
 
   
II. Meeting:
  * Date:       
Requested Start Time:
    Requested End Time:
  Location
   * Street Address:
  Suite/P.O.Box:
   * City:
   * State:
 * Zip Code:  -
   
   
III. Topic:
  * Subject desired:
    Time to be allowed:
    Will there be a question & answer period after speech?            
     
IV. Details of the program:
   

Other speakers (please list in order of appearance):

    Speaker One:
    Speaker Two:
    Speaker Three:
    Speaker Four:
    Speaker Five:
    Speaker Subject & Length of speech
   
     
V. Audience
    Estimated size:
    Composition of audience:
     
VI. Publicity:
    Will the meeting be open to the news media?
    Will the speech be broadcast?   
    Will the speech be taped, filmed or otherwise recorded?
   
VII. Equipment:
    Will sponsoring organization provide technology if required?
                                       
   
VIII. Miscellaneous:
 
 
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