Speaking Request Form - Pam Perry PR

Name of Workshop, Seminar, or Speaking Event*

Sponsoring Group*

Name of contact person*

First Last

Phone Number*

Fax Number

Email*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Meeting Specifics

Meeting Location*

Is meeting date fixed or tentative?*

Specific content to be covered?*

Specific meeting times*

Actual speaking time during each meeting*

Are there other speakers? If so, who?*

Number of attendees expected*

Median age of attendees*

What is the theme for your event?*

Are there any special needs you would like us to be praying about in regard to this seminar?

Honorarium (please write a specific U.S. dollar amount)*

The honorarium check should be made out to Pam Perry

Will honorarium be given in advance?*

Yes
No

The final day of meetings?

Special arrangements needed?

Overnight Accommodations

Hotel Name

Hotel Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hotel Phone Number

Logistics

Can you supply (check all that apply)

Any Special needs your organization may have when it comes to logistics

Expenses (Meetings less than 200 miles)

What is mileage from speaker's hometown?

Can you provide a detailed map?

Yes
No

Will auto travel of 33 cents per mile be covered?

Yes
No

Expenses (Meetings more than 200 miles)

(Air travel arrangements will be made by Pam Perry PR unless agreed otherwise)

Will air travel be covered in advance?

What is the length of travel time from airport to meeting place?

Who will transport to/from airport?

Please enter name above

Please provide the work and home phone numbers of the person above who will be transporting

Person Completing Form

Name of person completing this form

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number

Email

Fax number

Position/Title

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.