Speaking Engagement Request Form - The Advocacy Centre for the Elderly (ACE)

List 3 specific dates and times for the proposed presentation; or Confirmation of the date and time of the presentation if already determined *

Date

Time

Option #2

Date

Time

Option #3

Date

Time

The length of the presentation *

Name and brief description of the organization hosting the presentation *

Address of the host organization *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name of the contact person at the host organization *

Telephone number of the contact person at the host organization *

Email of the contact person at the host organization *

Purpose of the presentation *

Specific topic of the presentation for our speaker *

Is this engagement in person or remote? *

Description of the audience and number of attendees (ie seniors, language, etc.) *

Is an honorarium being offered, if so what amount *

Confirmation that you will cover all out of pocket expenses including accommodations, travel, parking, mileage *

Name of person/organization to direct our invoice

Address of person/organization to direct our invoice

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Are there any PowerPoint, projection, electronic and/or computer equipment available or required by us?

Any special instructions (including travel, parking, hotel, etc)

Will this be a private or public session? *

Do we have your authorization to post the session on our website with a link to your posting or website? *