Speaker Request fOrm

We appreciate your interest in having President Sam Epps speak at or attend your upcoming event. Please complete the following form, providing as much information as possible. We look forward to discussing your event with you.

Name

First Name

Last Name

Title

First Name

Last Name

Phone

(###)

###

####

Organization

Organization's Website

Event Name/Title

Event Type

(Monthly meeting, annual conference, panel, breakfast, lunch, dinner, banquet, etc.)

Event Date

YYYY

Event Start Time

Hour

Minute

Second

Event End Time

Hour

Minute

Second

Event Venue/Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parking Details

Approximately how many attendees do you expect?

What are your goals for President Epps's participation?

What level of participation are you requesting ?

(Keynote speaker, panelist, attendee, etc.)

What time will President Epps be speaking?

The time requested for the president’s participation should be as exact as possible, as there may be multiple engagements scheduled for a single day.

Does your organization have any special interests, topics, or concerns that you would like the President to address?

Should the President's remarks be formal or informal?

Formal

Informal

Other

Event Attire

Formal

Informal

Business Casual

Business Professional

Cocktail

Other

Day-of-Event, On-Site Contact

(Name & Cell Phone Number)