CEO Speaker Request Form

*Date of event:

*Time of event:

*Location of event (City/State):

*Audience (who and # of expected attendees):

*Length of speaking/presentation time:

*Format of request request (Welcome Address; Keynote Address; Panelist, etc.):

*Will Carmela be required to utilize PowerPoint?

Yes    No
 

If this is a panel, who are the other expected/anticipated co-panelists?
(please note names, organizations and titles)

 

Subject matter

 

*Is this CPCA/Healthcare related?
Yes   No

OR

*Is this Castellano Family Foundation/Philanthropy related?
Yes   No

 

*What is the topic you’d like Carmela to speak to? Please be as specific as possible.

 

Please indicate if there is anything else you would like Carmela to highlight or mention as part of the requested remarks?

 

*Does your organization plan to cover the speakers’ related travel costs to attend the event?
Yes   No

 


Is there a maximum reimbursement amount? If so, what is the maximum reimbursement allowed?
$

 

Speaker note: Carmela prefers a podium for all speaking engagements to audiences larger than 10 people.

 

*Your name:

 

Your organization:

 

Your title:

 

*Your phone number:

 

*Your email:

 

 

 

*required

 


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