SPEECH OR EVENT REQUEST

Day of Event Point of Contact (Name/Phone Number):*

Organization (Please type of the name of the organization meeting with the Rixys Alfonso.):*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name*

Organization Contact's First Name:* Organization Contact's Last Name:*

Title:*

Are you a Non-Profit:

Is this a special anniversary or commemorative event that the organization is celebrating?:

Work Phone:*

Cell Phone:*

Home Phone:*

Email*

About Your Organization

Brief Background (be specific):*

Has the Rixys Alfonso addressed your group in the past? (be specific on circumstance):**

Organization (Please no abbreviations):*

Event Title:*

Event Date(s):*

Preferred Date for Rixys Alfonso to speak/attend:*

Program Begins:*

Program Ends:*

Event City/State:*

Location (Please be as specific as possible):*

Is this a conference or annual meeting?:*

Brief Description of Event:*

Subject/Topic:*

Begin Speaking at:*

Number of minutes:*

Will the speech be followed by Q&A (if so, please elaborate on the type and time limit):*

Number of participants or people in audience:*

Description of Audience:*

Before/after/during a meal?*

Speaking order:*

Will this be a keynote address?*

Will there be an award or presentation?

Rixys Alfonso will be introduced by:*

Rixys Alfonso will be introduced by:

Press (open/closed):*

Podium (adjustable)?*

Teleprompter (if applicable):*

Attire:*

Will the speech be videotaped or posted on the organization's website?:*