Speaker Request Form

Thank you for your interest in having Denise Hughes speak at your event. In order to help facilitate your request, please complete and submit the following form at least 2 months prior to the event, and allow 3-5 business days for decisions to be made.

If you have any questions or need help completing the form, please call 650.592.8239, send me an email, or fill out an contact form .

Part 1: Event Organizer

Name of Organization Submitting Request (required)

Event Sponsor

Please select one of the following:
For ProfitNot for Profit

Coordinator/Point of Contact Name (required)

Coordinator/Point of Contact Title

Coordinator/Point of Contact Email (required)

Coordinator/Point of Contact Office Phone (required)

Coordinator/Point of Contact Cell Phone (required)

Part 2: Event Details

Event Name/Title (required)

Event Location (required)

Event Date/Time: (required)

Event Type: (required)
(conference, dinner, small group, etc.)

Event Purpose/Goal: (required)

Event Website:
(if applicable)

Part 3: Presentation/Speech Details

Requested Topic: (required)

Presentation Format: (required)
(keynote address, roundtable, panel, etc.)

Expected Duration: (required)
30 minutes, 1 hour, etc.)

Question and Answer:
(Will the speech be followed by a Q&A session?)
YesNo

Part 4: Audience Details

Audience: (required)
(Approximate size of audience. Also briefly describe its make-up and if membership is required to attend.)

Honorable Guests
(List names and titles of members of Congress, CEOs, or other VIPs participating in, or attending the event.)

Media: (required)
(Will media be invited? If so, will the event be open or closed press?)

Part 5: Additional Information

Deadline for Acceptance:

Cost of Attendance (required)
(please include member and non-member price, if applicable)

Offer of Payment/Reimbursement: (required)
(amount, dining, lodging, travel, etc.)

Disclaimer/Release Form:
(Please indicate whether or not the event sponsor will need the speaker to sign a disclaimer/release form.)
YesNo

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