Speaker Request Form Organization/Company Name: Contact Name: Title: Address: Phone:
Fax:
Email:
Website:
Organizational/Company Overview (please provide mission statement and any other information that might describe your organization or company such as membership or chapter information): Detailed Description of Speaker Request (please provide intended program, topic, format, length, other participants, audience) Specific Date(s) Requested: Location: Travel Expenses Covered
Yes
No
Honorarium Included
Yes
No
Amount: $
Additional Information (please provide any additional information you would like us to consider when processing your request, for example, additional fundraising opportunities) Please return attention to Dan Ettinger / 370 Lexington Ave., Suite 401 / New York, NY 10017 Forms can also be faxed to (212) 573-8047 or emailed to dettinger@seedsofpeace.org. Questions? Call the New York Office at (212) 573-8040
For internal purposes only: request received on _______________