ORAU/ ORISE Speaker’s Bureau
Speaker Request Form
To request a speaker, print this document, answer the following questions and return it to:
Speaker's Bureau Coordinator
P.O. Box 117 MS #44
Oak Ridge, TN 37831-0117
Phone: (865) 576-5156
Fax number: (865) 241-2923
Your full name _________________________________________________________
Your organization’s name _________________________________________________
Your organization’s address _______________________________________________
Daytime phone number __________________________________________________
E-mail address (optional) _________________________________________________
Preferred speaker _______________________________________________________
Alternate speaker _______________________________________________________
Topic of discussion ______________________________________________________
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Requested date and time __________________________________________________
Location of presentation __________________________________________________
Title of your event _______________________________________________________
Theme of your event _____________________________________________________
Expected attendance (approximate number) ____________________________________
Audience makeup (high school students, area business professionals, etc) _______________
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Length of talk required ____________________________________________________
Will there be other speakers at this event? _____________________________________
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Will the requested speaker be the keynote speaker? _____________________________
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Who will handle the publicity of the event? ____________________________________
Additional information ____________________________________________________
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