Speaker Information Form

Speaker's Name*

First Last

Cell Phone*

Email*

Spouse Name, if applicable

First Last

Assistant's Name, if applicable

First Last

Assistant's Phone Number

Assistant's Email Address

Travel Information

Arrival Date & Time*

Arrival Airport, if applicable

Arrival Airline & Flight Number, if applicable

Departure Date & Time*

Departure Airport, if applicable

Departure Airline & Flight Number, if applicable

Will Anyone Be Traveling With You?*

Yes, someone is traveling with me.
No, I am traveling by myself

Who is traveling with you?

Resources & Shipping Information

Will you be selling resources at the Event?*

Yes, I will be selling resources.
No, I will not be selling resources.

Will you ship your resources or bring them with you?

I will ship my resources in advance.
I will bring my resources with me.

Name of Resource Table Attendant, if applicable

First Last

Audio/Visual Information

What microphone do you prefer to use when speaking?*

Wireless headset
Handheld

Will you be using either of the following visual aids?

Video Clips or Roll-Ins
Power Point
No, I will not be using these visual aids.

Do you have an special audio/visual needs? (Plug-ins, Music, etc)*

Yes, I have special audio/visual needs.
No, I do not have any special audio/visual needs

Please list any additional audio/visual needs:

General Information

Are there any special needs you would like to make us aware of for your time at the Event?

Honorariums and expense reimbursements, if applicable per your invitation letter, will be paid via check during the Increase Event or mailed to you after the Event concludes.

Check made payable to:

First Last

Mailing Address

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