I am interested in booking:

Name of Sponsor/Organization: *

Contact Person and Title: *

Email Address: *

Phone Number: *

Fax Number: *

Mailing Address: *

Proposed Date(s):

Event Description/Speaker's Theme/Speaker's role (i.e. Keynote, workshop, moderator, etc.)

Event Registration Fee (please indicate if the event is free to students):

Preliminary schedule for speaker

Estimated Number of Attendees:

Event Demographics:

Venue Location:

Speaker’s Fee Offered: (Note: you would also be responsible for all travel, food per diem & accomodation expenses)

Nearest Airport to Venue:

Approximate Event Ticket Price: