Speaker Request Form

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Speaker Request Form
Please complete and submit this form to request Lucy as Speaker at least 30 days prior to the date of your event. Her goal is to respond within 24 to 48 business hours upon submission of this form.

Your Contact Information

* Indicates required field

Contact Name *

First

Last

Position *

Phone Number *

Email *

Organization *

Organization Website *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Program Description

Date & Time of Program *

Theme or Purpose of Program *

Time of Speaker's Presentation (plus length) *

Language Preference of Speaker Presentation *

Approximate Size of Audience *

Describe your Audience and what you'd like them to takeaway from presentation. *

Event Location & Address *

Line 1

Line 2

City

State

Zip Code

Country

Additional Information You Would like to Note *

Equipment and A/V Available for Speaker Use

Check those available *

Projector for PowerPoint Screen Microphone Flip Chart, Easel, Markers Presenter Work Table Extension Cords None available

Specifics of Event

Is this an annual event? *

Yes No

What is your Speakers Budget? *

Which of these apply to your event? *

It will be videotaped. It will be audio recorded. There will be media coverage. None apply to event

Name of Airport Closest to Event *

Speaker Fee Information

Presentations are Fee Based plus Travel Expenses.
Final confirmation made once a contract or agreement is initiated, completed & signed by both parties.

Name of Person to be Invoiced *

Phone Number *

Email Address for Invoice Purposes *

Note: If you do not have a Speaker's Budget, Ms. Cantú offers a limited number of speaking engagements yearly for an Honorarium and travel expenses. Please submit this completed Speaker Request Form and explain the special circumstances of your organization for consideration. We will contact you with response.

Explanation: *

Submit

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