Speaker Request Form

Questions? Call 1(234) 567-48900*
Name of contact person*
Mailing Address*
Meeting Specifics*
Honorarium (please write a specific U.S. dollar amount)*
Overnight Accomodations*
Hotel Address*
Expenses (Meetings less than 200 miles)
Expenses (Meetings more than 200 miles)
Expenses Name of person completing this form

NOTE: After we have sent you a letter confirming all arrangements, a cancellation fee of 25% of the honorarium will be assessed on the party who cancels the engagement. The canceling party will also be responsible for any non-refundable airfare/travel costs or misc. expenses.

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