Speaker Request Form

Name of club:(Required)

Month of AGM:

Membership Numbers:

Expected attendance:(Required)

Group type:

Preferred date of talk (Please list 2 options):(Required)

Option 2 date:(Required)

Preferred start time:(Required)

 (The presenter will speak for a total of 45 minutes including question time.  We kindly request that our representatives speak first on the agenda where possible.)

Meeting Address:(Required)

 (please provide direction if required)

Additional Notes:

 (Please provide extra detail and specific instructions such as arrival time, meeting start time, presentation time)

Contact Name:(Required)

Position in club:(Required)

Contact Number:(Required)

Contact Email:(Required)

Are you the best contact person for the date of the talk?(Required)

 (If no, please provide their details below)

Contact Name for the day/night of the talk:

Contact Number:

Contact Email:

Phone

This field is for validation purposes and should be left unchanged.

Neutrog

Factory Tour

Speakers

Speaker Request Form