Speaker Request Form

SPEAKER REQUEST FORM:
Event Point of Contact: First Name: (required) Last Name: (required) Email: (required) Phone Number: (required)
Name of requested speaker? First Name: (required) Last Name: (required)
If the speaker you are requesting is unavailable, will you be interested in an alternate? (required) YesNo Name of your group or organization. (required) Is speaking engagement part of a conference, a local event, a business chamber meeting, or another type of event? (required) Enter name of event (required) Date of event: (required) Time of Event: (required) Desired length of time: (required) Approximate size of the audience: (required) Briefly describe the audience in attendance. (required) Is there an event theme? (required) Requested topic. (required) Please provide event website (if available). Will media be invited? (required) YesNo Will the GPA representative be the sole presenter or part of a panel? (required)

Who will introduce the speaker?
First Name: (required) Last Name: (required) Title:

Name and title and biography of moderator:
First Name: (required) Last Name: (required) Title: Moderator Bio (3 MB Max): Names and titles and biographies of other panelist?
First Name: (required) Last Name: (required) Title: Panelist Bio (3 MB Max): First Name: Last Name: Title: Panelist Bio (3 MB Max): First Name: Last Name: Title: Panelist Bio (3 MB Max): First Name: Last Name: Title: Panelist Bio (3 MB Max): If available, please attach an abstract on the panel or the Run-of-show listing speaker order, time slots, etc.

Is your event virtual or in person? (required)

What platform will you be using (Zoom, Microsoft Teams, other)? (required) Will you allow a few PowerPoint slides? (required) YesNo Will you allow video as part of the presentation? (required) YesNo Please provide the date you will be available to test-run the presentation. (required) Who will control the sharing of content during the webinar? (required)

Where is the venue?
Venue Name: (required) Address 1: (required) Address 2: City: (required) State: (required) Zip Code: Will you allow a few PowerPoint slides? YesNo Do you allow video as part of the presentation? YesNo What screen size (aspect ratio) will you have? Who is the Point of contact receiving the advance presentation?
First Name: Last Name: Email: Phone number: Will you have a dedicated A/V team or person on-site in case of technical issues? (required) YesNo Will there be a confidence monitor so the speaker can face the audience and still see the presentation? (required) YesNo

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