Speech Appearance Request Form

Today's Date^*

Requesting Institution/Organization:^*

Type of Event:^*

If event is a panel discussion or panel presentation, please provide the list of other panelists and the topics that they have been asked to speak about:

Event Title:^*

Conference Hosts/Sponsors:

Date, Time and Length of Presentation:^*

Requested Title of Board Member Presentation^*

Audience Size:

Makeup of Audience (Trustees, Faculty, College Presidents, etc.):

Venue Name:^*

Venue Address:^*

Street Number

Street Address

City

State

Country

Zip Code

Nearest Airport

Institution/organization will provide round trip ground transportation between airport/train station to hotel/meeting site^*

Ground Transportation Contact Info

LODGING

Name of Hotel:

Hotel Phone Number:

Hotel Address:

Street Number

Street Address

City

State

Country

Zip Code

Host/Sponsor will handle hotel reservation:

Reservation Confirmation:

CONTACT PERSON FOR EVENT

Name:^*

Title:^*

Address:

Street Number

Street Address

City

State

Country

Zip Code

Contact Number:^*

Email^*

Board Member Audio Visual and Other Requests:

Large projection screen w/LCD projector and remote advancer
Tall stool with back behind the podium to the side
Laptop with presentation preloaded (on podium) or a flat screen monitor (if applicable) at the base of the stage so slides can be easily seen
Podium microphone if addressing a group of more than 40 people

REIMBURSEMENTS

Will expenses be reimbursed?

Please specify what expenses will be covered:

Please attach claim form if required.

Will Honorarium be provided?

Please indicate name/address of Individual to whom claim for reimbursement request should sent:

Name:

Address:

Street Number

Street Address

City

State

Country

Zip Code

M	T	W	T	F	S	S
						1
2	3	4	5	6	7	8
9	10	11	12	13	14	15
16	17	18	19	20	21	22
23	24	25	26	27	28	29
30