It’s In The Genes, LLC  Speaker Request Form  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Date of Event: __________________   Start Time: __________________  End Time: __________________   

Event Title:  ______________________________________________________________________  

Event Address:  ___________________________________________________

Name of Sponsoring Organization: ___________________________________________________ 

Contact:  E-Mail: ___________________________________  Office #:   __________________________________

Organization’s Affiliation with iitg (if applicable):  __________________________________

Is the request for a keynote speaker, guest speaker, or a panelist? __________________________________ 

Theme of event or topic of discussion: __________________________________ 

What is the expected talk time? __________________________________ 

Who is the audience? __________________________________  

How many members/guests are expected to attend? __________________________________ 

Name of individual introducing the speaker: __________________________________ 

Are other speakers/officials attending the event? Yes (   )     No (   ) 

If so, what are their names?  __________________________________

Is there an honorarium available for the presentation?  Yes (   )     No (   ) 

If the event is in a hotel, what is the room name? __________________________________ 

Hotel phone #:  __________________________________          Hotel fax #: __________________________________ 

What audio-visual equipment is available? 

If travel is involved: __________________________________

Hotel budget: __________________________________Travel budget: __________________________________

Additional Information:    

If you have any questions, please call us at 301.683.8690 or e-mail : dosomething@itsinthegenes.com