Event Speaker Request Form

    Host Organization:

    Website of Organization:

    Proposed Dates & Times:

    Contact Person Information

    Contact Name* (first,last):

    Contact Email*:

    Contact Phone*:

    Contact Mailing Address:

    Event Info

    Name/Title of Event:

    Theme of Event:

    Preferred topic:

    As a speaker, what need can Bob fill for your event?:

    Time required (Include speaking and autographing books):

    Estimated number of people attending:

    Location (Include venue, street address, city & phone):

    If necessary, can organization provide assistance with book sales?:

    Driving directions form major highway:

    Please enter the the following code into the box: