Speaker Request Form

Event name:

Organization Name*:

Event Location:

Date Requested*:

Tell us about your event (e.g. agenda, content, purpose, other featured speakers):

Expected audience size & background:

Preferred WMA Speaker(s):

Format of speaking opportunity, e.g. keynote, panel, workshop

Will your organization offer an honorarium? If so, please include the dollar amount.

Will your organization cover travel and lodging expenses?*
YesNo

Your name*

Your email address*

Your phone number

Organizer's name*

Organizer's email address*

Organizer's phone number

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