Speaking Engagement Request Form
for Dr. Shockley-Zalabak

Event Information

*Date of Request:
*Name of Event:
*Location:
*Date of Presentation:
*What time does event start?
Where should Dr. Shockley-Zalabak park?

Speech Information

*What time will the speech start?
*Type of Speech:
*Speech Topic:
*Length of Speech:
*Who will be in the Audience?
*Audience Size?
*Will there be a podium?
*Q & A Session?
*Who will introduce Dr. Shockley-Zalabak?
*Please list other speakers/attendees:
Will there be media in attendance?
If yes, please list who (if possible):
Is there anything else you should tell us? Please send any background materials (draft form is okay) such as an agenda or program a week prior to event.
*What does your audience want the Chancellor to speak about?
*What type of microphone will be used
(lapel, podium, hand-held)?

Contact Information

*Email of the on-site contact person:
*Cell Phone Number of the on-site contact person:
*
Validation Code
[?]
* denotes required field