Speaking Request Inquiry Form

Your Information

First Name

Last Name

Email *

Phone

What is your title/role at your organization? *

Organization (no abbreviation) *

Organization Zip code *

Organization Address *

Organization City *

Organization State/Province

Organization Details

Please provide a description of your event, learning objectives, event goals and/or the speaker's expected role. Not sure? That's okay! We're happy to help you plan. *

Organization Type *

Professional/Corporation

Nonprofit/NGO

Foundation

Are you a member? *

Yes

How did you hear about us? *

Please let us know who, if anyone, referred you to this program.

Event Details

Which type of event format are you interested in hosting?

Virtual Event

In-Person Event

Who is your target audience? (check all that apply) *

What is the focus of your event? (check all that apply) *

What is your speaker budget? *

Event Planning Information

What is your 1st preferred date for your event? *

What is your 2nd preferred date? *

Preferred time of presentation?

Have you previously hosted an Active Minds Speaker?

Does your organization require the use of its own performance agreement/contract?

Billing Contact First Name

Billing Contact Last Name

Billing Contact Title/Role

Billing Contact Email Address