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Author/Artist you are interested in

Last Name

First Name

Title/Position

Name of Sponsoring Organization

Date(s) of Your Event

Name or Type of Event

Address of Sponsoring Organization




Website for Organization

Office phone

Home Phone

Mobile Phone

Your Email Address

Name of Venue where event will take place (if different from Sponsoring Organization’s Facility)

Anticipated Audience Size

Address of Venue place (if different from Sponsoring Organization’s Address)




Website for Venue

Website for your event

How many days commitment do you anticipate from the Author/Artist?

How many times would Author/Artist speak/perform?

How long would you like Author/Artist to speak/perform?

Please supply any other details that would be useful to Author/Artist in considering your event