Speaker Request Form

Request a Speaker

All fields required.

About Organization

Organization Name

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Organization's Website

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Primary Contact

First Name

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Last Name

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Title

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Email Address

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Office Phone

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Cell Phone

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Event Details

Date of Event

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Time of Event

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Address

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Suite / Room #

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City

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State

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Zip

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Audience Size & Composition

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Preferred Speaker

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If the preferred speaker is unavailable, will you accept another speaker from CSB?

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Anticipated Role

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Other Anticipated Panelists/Speakers

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Presentation Duration

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Will there be Q & A?

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If Q & A, Please provide additional details on the format of the program

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What topic would you like CSB to speak about? What perspective would CSB add to your event?

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If a Powerpoint presentation is being used…

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Will you have AV equipment at the location?

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Will you need a speaker bio, photo, or other info? Please specify.

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Specify the speaker’s arrival time, where to report, etc.

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Provide contact info for the “Day of Event” contact if different from yours.

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