Speaker Request Form | Better Place

Julie Mullins
Better Place
M: 650.387.0486
Julie.Mullins@betterplace.com

speaker request

* required field

First Name *

Last Name *

Title

Organization *

Website

Email *

Phone *

Mobile

Fax

What type of participation are you looking for? Select all that apply. * SpeakingSponsorshipExhibition

Name of Event *

Event Start Date * (MM/DD/YYYY)

Event End Date * (MM/DD/YYYY)

Will Speaker Travel Expenses Be Covered * YesNo

Are media expected at the event? * YesNo

Is a slide presentation required? * YesNo

Event Location

Street Address *

City/Town *

State/Province *

Zip/Postal Code *

Country *

Event URL

How many times has this event been held? *

What is the overall event focus (for example, all electric vehicle conference)? *

Describe the audience/participants for the event (including estimated audience size) *

Who is your preferred speaker? *

Are you open to other speakers? *

If you are requesting a speaker, what type of format is it? *

Please list the planned and anticipated speakers *

What is the primary topic(s) for the speaking opportunity? *

If a sponsor or exhibit opportunity, please describe (category, level, benefits, pricing) *

Please list confirmed sponsors *

What are your deadlines for the event? *

Additional information to help us evaluate this request?

Please attach any relevant materials (ex. event agenda, media lists, list of previous attendees, sponsor package, etc.)