Primary Contact Person

Email Address

Phone Number

Organization Name

Presentation Type

Poetry Performance

Lecture

Keynote

Panelist

MC/Host

Other:______________

Speaking Fee/Honorarium Budget (not including travel accommodations)

Event Location

Event Description

Event Date

YYYY

Event Time

Hour

Minute

Second

Expected Number of Attendees

Duration of Performance/Speaking

Travel/Lodging Accommodated?

Dress Code

Q&A Session following event