Speaker Request

SPEAKER INFORMATION Please submit the following required items marked as “*” all other information is optional. Speakers' email and phone numbers will not be published or shared unless requested by the speaker.

Name

Email

Phone

Event Company/Organizer: *

Event Title: *

Event Location: *

Event Type:

Speaker Requested: *

Speech Date

Speech Time & Duration: *

Speech Topic: *

Presentation Format:

Question & Answer Period:

Yes

No

Will there be a moderator:

Yes

No

Audience:

Purpose:

Open Press/Closed Press:

Yes, Open to Press

No, Closed to Press

Registration Cost Covered By Host:

Yes

No

Travel & Lodging Covered by Host:

Yes

No

Host will reimburse speaker for:

Flight

Hotel

Ground Transportation

Other Expenses/Activities?

What other expenses/activities will be included?

Event Website:

Event Sponsor:

For Profit/Not for Profit:

For Profit

Not for Profit

Offer of Payment/Honorarium/Reimbursement:

Event Agenda:

Deadline for Acceptance:

Coordinator Point of Contact:

Disclaimer/Release Form:

Captcha

Speaker Request

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Utilities Technology Council