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Speaker Request Form:  Please note that we work with limited resources and are   unable to meet all requests.  Speaking engagements that cover expenses, offer   honoraria, and expose the organization to a large audience will receive priority   consideration. 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 Jessie Post / 370 Lexington Ave., Suite 2103 / New York, NY 10017 Forms can also be faxed to (212) 573-8047 or emailed to jpost@seedsofpeace.org. Questions? Call the New York Office at (212) 573-8040 For internal purposes only: request received on _______________


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