Speaker Request Form | Nicole Tetreault, PhD

NAME

EMAIL

PHONE

LOCATION OF EVENT

ORGANIZATION

PREFERRED DATE

ALTERNATE DATE

DESCRIPTION OF YOUR REQUEST

PROPOSED SPEAKER FEE

WILL YOU COVER TRAVEL EXPENSES?

Airfare

Hotel

Ground/Mileage

Meals

Unable to cover expenses (or no travel is required)

IS THE EVENT OPEN TO THE PUBLIC?

Yes, it is open and free to all.

No, this is a private event.

Yes, but registration is required.

Don't know or have not decided whether this event is open.

PLEASE ADD ANY ADDTIONAL INFORMATION HERE

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