Contact Me

Requester Name *

First Name

Last Name

Requester Phone *

(###)

###

####

Requester Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Event *

Check all that apply.

Training

Conference/Keynote

Presentation/Workshop

Fundraiser

Consulting Project

Other

Event/Project Date *

MM

DD

YYYY

Event/Project Start Time *

Hour

Minute

Second

AM PM

Event/Project End Time *

Hour

Minute

Second

AM PM

Do you have any audio-visual capabilities? What will you be able to provide? *

Please check all that apply.

Microphone

Computer

Screen/projector

DVD capabilities

PowerPoint capabilities

Virtual platform (please specific which in the notes below)

Someone on site/or virtual to help with tech set-up

Please read and agree to the following disclaimer. *

Completing this form is not an automatic guarantee that I will be able to accommodate this request. Once I receive your information, I will follow up with next steps. Thank you! Should any question arise from the information you have provided in this form, please, respond within 24 hours. Thank you for your understanding and cooperation. Please mark “YES” below to acknowledge that you have read and understood this disclaimer. Thank you for your cooperation.

Yes, I have read and understand the disclaimer.