Speaker Request Application

Event Organizer:*

First Last

Name of Organization:*

Event Sponsor(s):

Is your organization a nonprofit?*

Yes
No

Address*

Street Address City State / Province / Region ZIP / Postal Code

Email*

Phone*

Event Information

Event Name/Title:*

Event Location (physical location, URL, or other relevant information):*

Event Date*

Event Date – Ending

Start time of event

Approximate length of presentation

Event Type (conference, dinner, small group, etc.):*

Event Purpose/Goal:*

Event Website (if applicable):

Audience Details

What is the estimated size of your expected audience?

Can you describe this audience? (i.e., members of your organization, families, entrepreneurs and local business leaders, etc.):

Presentation/Speech Details

What topic(s) would you like a Food Bank representative to cover?*

Presentation Format (Is this an invitation for a keynote address, roundtable, panel, etc.):*

Expected Duration of Presentation (10 minutes, 1 hour, etc.):*

Will the speech be followed by a Q&A session?*

Yes
No

If a physical, in-person event, will you be providing a PA system?*

Yes
No

Honorable Guests

Please list names and titles of political leaders, CEOs, or other VIPs participating in or attending the event:*

Media

Will media outlets be invited?*

Yes
No

If yes, will the event be open or closed press?*

Open
Closed

Please describe your media list:

Additional Information

Is there a deadline by which you need to confirm a speaker from the Food Bank?*

Cost of Attendance (Please include member and nonmember price, if applicable):

Does your organization plan to make a donation to the Food Bank in conjunction with the event?

Yes
No

If yes, what is the estimated dollar amount?

Other costs (Dining, lodging, travel, etc.)*

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Overview

Speaker Request