Speaker's Name:____________________________________________________________
Address: ________________________________________________________________
Telephone: Work ________________ Home _______________ Fax _______________
Organization:____________________________________________________________
Event: _____________________ Date of presentation: _____________ Time: _______
Title of presentation:_________________________________________________________
Description of Presentation:__________________________________________________
________________________________________________________________________
Invited by:__________________________ Date confirmed:_________________________
Date confirmation letter sent:________________________________________________
Travel Arrangements:______________________________________________________
Arranged by: _____________________________________________________________
Hotel Accommodations: ____________________________________________________
Arranged by: _____________________________________________________________
Honorarium: Yes _____ No _____ Amount $
Travel expenses: Yes _____ No _____ Amount $
Hotel expenses: Yes _____ No _____ Amount $
Audiovisual aids requested: Yes _____ No _____ No Reply _____
Staff member assigned to greet/accompany to conference: __________________________