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: