Speaker Request Form

Contact Details

Name * Enter your full name

Position *

Organisation *

Email address *

Contact Number

Event Details

Event Name and Description * Enter the name of your event and what it’s about

Event Date * Enter the date of your event

Event Location * Enter the location of your event

Requested Speaker * Enter the name of your requested speaker

Audience * Size and description of audience

Format and Purpose * Enter the type of format, purpose (e.g. speech, presentation, panel, Q&A etc.) and the approximate duration

Moderator * Who will moderate or MC the session

Theme * Enter the theme for discussion.

Is the event open to media? *

• Yes
• No

Will the event be recorded? *

• Yes
• No

Other speakers * Which other speakers have been confirmed

Additional Information Please enter any further details including origins of the event, links to campaign websites or flyers and context to help us assess the invitation. As well as any key messages you would like the speaker to get across.