Prefix: Mr. Mrs. Ms. Dr.

First Name:*

Middle Name:

Last Name:*

Suffix:

Title:

Organization:

Address:

Address 2:

City, State, Zip:

Day Phone:

Evening Phone:

Mobile Phone:

Fax:

Email:

PROGRAM INFORMATION:

The purpose of this application is to gather as much information from you as possible so that PVLA can make the most appropriate speaker assignment for your needs and requirements. The more detail you provide the better we can server you.

1. Who is the audience you would like to address:
Our anticipated audience is made up of . . . tell us the anticipated: Size, Type and Background of your audience.

2. What specific interests or topics should be addressed by this speaker or event?

3. What specific expectations do you have for this event and what information or new knowledge should the attendees have upon its completion?

SPECIFIC EVENT INFORMATION:

Title and Description of Program - Include 3 or 4 topics to be covered:
The title of our program is . . .

Program Day & Date:

Weekday: Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Month: January February March April May June July August September October November December

Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year: 2008 2009 2010 2011 2012

If this event is more than one day long, please provide date range:

Program Start Time:

Program Length: Less than 1 hour 1 hour 1.5 hours 2 hours 2.5 hours 3 hours More than 3 hours

Location of Program (include a street address):

Location of Program:

Program Venue: Conference Room Classroom Auditorium Other

If other venue, please list:

Program Format: One Speaker Lecture One Speaker Interactive Panel Discussion Other

If other format, please describe:

The following AV items are available:
Slide Projector Overhead Projector Video Projector Blackboard or Easel

PROGRAM FEES:

The fees for Speaker's Bureau activities are charged on a sliding scale based on the size of your organization, your ability to pay, and the scope of the program you are requesting. Our suggested fees range from $150 to $300 per program. If you have an extenuating circumstance or need subsidy to suppport your request, please let us know in advance.

We have budgeted $ for our request:

If you have additional information which will help us better understand or meet your request, or there is additional information you would like us to know about you, you may enter it here:

Additional Information:

Thank you for taking the time to complete this form.