Speech evaluation

* denotes required field

*Audience Size (minimum 25)  
Date and Time of Speech
*First preference *Date: *Time:
Second preference  Date:  Time:
*Speaker Arrival Time
Information About Your Organization
*Organization name
*Web address
*Briefly describe your organization
Group Type:
hold CTRL + click to select more than one
Contact Information

*First Name:

*Last Name:

Title:

*Phone:

*Email:

Fax:

Topic(s) of Interest
*First
Second
Third
Event Information
*Location
*Address
*City

*State *Zip

Phone

Directions
Parking arrangements
*Audience Type
Describe
Speech

Welcome

Introduction

Keynote

Workshop

Remarks
Other
*Program Format

Breakfast

Lunch

Dinner

None

Other

 
Length of Speech

30 minutes

45 minutes

1 hour

Other

*Q&A

During speech

After speech

None

 
Length of Q&A

15 minutes

30 minutes

Other

Panel discussion

Yes

No

Panelist names, titles and organizations
NameTitleOrganization
 

 
Length of Panel discussion

30 minutes

45 minutes

1 hour

None

Other

Moderator

Yes

No

Moderator NameTitleOrganization
*Event open to news media

Open to public or media    Comments:

Possible    Comments:

Not open to public or media

*Event to be broadcast?

Yes, please explain

No

Speaker bio needed?

Yes

No

Speaker photo needed?

Yes

No

Event Agenda and/or Press Release

Please email agenda and/or press release to patricia.a.demaioribus@clev.frb.org

A/V Equipment Available
(select one or more)
Laptop
Podium with microphone
Projector
Screen
Lapel microphone
Wireless mouse
Wide-screen TV monitor
How did you learn about our Speakers Bureau?
(select one or more)
Website

Referral

If referral, please explain: