Speaker Request Form

Name of club:

Month of AGM:

Membership Numbers:

Expected attendance:

Group type:

Preferred date of talk (Please list 2 options):

Option 2 date:

Preferred start time:

 (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:

 (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:

Position in club:

Contact Number:

Contact Email:

Are you the best contact person for the date of the talk?

 (If no, please provide their details below)

Contact Name for the day/night of the talk:

Contact Number:

Contact Email:

Name

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Speakers

Speaker Request Form