
		photo: derek goodwin

Speaking Request

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Contact Person:
Name of Organization:
Street Address:
City:
State:
Zip:
Day Phone:
Evening Phone:
Copy of request will be sent here: E-Mail:
Preferred Means of Contact:	Day Phone Evening Phone E-Mail
Website:

Seating Capacity:
If Sponsor and Venue are different,	Please Check:

Copy & Edit data from Sponsor:
Contact Person:
Venue Name:
Street Address:
City:
State:
Zip:
Day Phone:
Evening Phone:
E-Mail:
Preferred Means of Contact:	Day Phone Evening Phone E-Mail
Website:

Note: Date & Time selections are optional. Please indicate if tentative and/or preferred in comments below.
First Choice, Date & Time:	Click to select Date & Time
Second Choice, Date & Time:	Click to select Date & Time
Third Choice, Date & Time:	Click to select Date & Time
Time Zone:
Number of People Expected:
Audience:
Preferred Topic:	Please see http://www.veganmd.org/talks.html for details on current topics.
Is this part of a larger event?	If so, Please Check: and include the full schedule below.
	* please describe below

Is there something to write on?	No Whiteboard Blackboard Flip Chart *Other
Is an LCD projector available?	No Yes
Is a projection surface available?	No Projection Screen Blank Wall *Other
Is there a support for lecture notes?	No Podium Music Stand *Other
Microphone / amplification system?	No Yes
Is there an 'emergency' cell phone number for last minute contact?	Cell Phone Number:

I don't like to impose on people... I'm just wondering:
Can someone drive me to and from the bus/train/airport and locally?	No Yes
Driver's Name:
Can the driver be reached by cell phone in case I'm delayed, etc.?	Cell Phone Number:
I may arrive without a chance to eat. Can You arrange a vegan snack?	No Yes
Are funds available to help defray my travel costs?	No Yes
Can Your organization offer an honorarium?	No Yes
Would You be comfortable 'passing the hat' at the event?	No Yes
*Where can I be put up overnight?	Hotel Someone's House Other
Can You photocopy handouts?	No Yes
I may bring books or DVDs, can someone assist sales during Q & A?	No Yes
How are you planning to publicize the talk?	Please describe below, also please email me any fliers, news releases or promotional emails you are using, so I will know what the audience is expecting: mhg1@cornell.edu
	* please describe below

Additional Comments: Note: In case I decide to drive, please include directions from a major road to the venue and/or the place where I'll be staying.


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