Speaking Request Information

To enable Ms. Lord to best accomodate your request to speak at your event, to your group or company,
please answer the following questions. If required information is not yet known, simply fil-in "TBD"
Note: fuller submissions and flexibility increase our ability to meet your request):

1. Contact Information
Your Name:
Your Title:
Organization Purpose:
State: Zip:
Office Phone:
Alternate Phone:
  3. Speaker Considerations & Requirements
Travel (airfare & hotel)  
Nearest Major Airport
To Event Location:
Other Considerations:  
Time frame in which decision is
needed from Ms. Lord:
Materials required from Ms. Lord:

Deadline for materials
from Ms. Lord
How did you hear about Ms. Lord?

2. Event Information
Name of Event:
Type of Event
Event Frequency:
Preferred Date(s):
Alternate Date(s):
Event Time(s):
Group Size:
Event Address:
Event State: Zip:
Location Phone:
Location Fax:
  4. Speaker Presentation Information
No. of speakers appearing:  
Time Allotted to Ms. Lord  
Preferred Topic:  
Secondary Topic:  
If there will be multiple speakers at the event, please describe the topics that will be covered briefly:

(maximum response 255 characters)