Speaker Request Form

1. Organization Name: Please provide the official name of your organization.

First Name

3. Email

Last Name

4. Contact Phone Number: Best number to reach you.

5. Event Title: What is the name of your event?

6. Event Date(s): Please include all dates relevant to the event.

7. Event Time(s): Specific times for the keynote, breakout sessions, and networking events.

8. Event Location (City/State/Country): Please provide the full address if known.

10. Estimated Audience Size:Approximate number of attendees.

11. Audience Demographics: Who will be attending? Please include job roles, industries, and any other relevant details about your audience.

12. Key Event Goals:What are the main objectives of this event?

14. Expected Duration of Keynote/Speaking Segment: Please indicate the estimated time (e.g., 30 mins, 1 hour, 90 mins).

15. Topics or Themes to Emphasize: Please list any specific themes, topics, or key points you’d like Shirley to cover.

17. AV Requirements and Equipment Provided: Please include details about the stage setup, microphone type, projector, screen, etc.

18. Expected Arrival/Departure Dates and Times (for In-Person Events): Include any required travel days if applicable.

19. Venue Details and Accessibility (for In-Person Events): Include information about the venue size, layout, and any travel or accommodation arrangements.

20. Speaker Budget Range: Please provide an approximate budget for this speaking engagement.

22. Any Other Expenses Covered (meals, ground transportation, etc.)? Please specify what costs will be covered by the event organizers.*

25. Will the Event Be Promoted on Social Media and Other Platforms? Please include details on how the event will be marketed.

26. Is There Anything Else We Should Know to Tailor This Experience? Please include any special requests or additional information.

Event & Organization Details

Speaking Engagement Requirements

Event Logistics & Technical Requirements

Budget & Financial Details

Marketing & Promotion

Additional Information