Speaking Engagement Request Form Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send. Requestor / OrganizerContact Name *Phone Number *Email *Alternate NameAlternate Phone NumberAlternate EmailInformation About Requesting OrganizationName of Organization *Organization WebsiteDescription of Organization Information About EventEvent Title *Start Date *Start Time *End Time *End Date *End Date Start Time *End Date End TimeEvent WebsiteVenue *Address (Street, City, State, Zip) *Description of Event *Audience SizePrimary Language of Expected AudienceAudience TypeCommunityGovt. AgencyLegal / ProfessionalOther Audience TypeAudience Knowledge of Topic (limited / knowledgeable / very knowledgeable)Agenda / Schedule Available for EventYes (if yes, please provide a copy to firstname.lastname@example.org)NoSpeaker and Participation DetailsRequested Speaker (if known)Speaker Participation Format (keynote speaker, panel member, etc.)Speaker Participation Date and TimeDateTimeSpeaker Length of ParticipationTopic of Presentation *Photo NeededYesNoIf yes, due date neededBiography of Speaker NeededYesNoIf yes, due date neededAudio / Video / Materials NeededYesNoIf yes, due date neededWill you need a master copy of speaker's handout / material prior to the event for reproduction and distribution (The master copy(s) will be sent electronically as a pdf)? If yes, due date neededTravel InformationRecommendation(s) for hotel accommodations that provide government ratesHotel Name #1Phone NumberHotel Name #2Phone NumberClosest Airport to the EventMap / Direction from the Airport to the Hotel and Event LocationOn-Site Contact During EventContact NameEmailPhone NumberFax NumberToday's DateToday's Date *WebsiteSUBMIT FORM NOTE: DFEH staff cannot accept speaker fees, honorariums, or travel expenses. The external host may waive the speaker’s registration or conference fees.