SPEECH REQUEST FORM

Date request made: (required)

Response needed by: (required)

SPONSOR INFORMATION

Organization Name: (required)

Contact Person: (required)

Contact’s Relationship to Organization: (required)

Phone: (required)

Email: (required)

Fax:

Web:

EVENT INFORMATION

Type of Event (check all that apply):
 Single Topical Speaker Course Teacher Conference Fundraiser Seminar Other

Event Location (address): (required)

Event date and time: (required)

AUDIENCE

Type of Audience (check all that apply):
 Male Female Muslims Members of other faiths Youth Adults

Will this speech be (check all that apply):
 Audio Recorded Video Recorded Transcribed Live-Streamed No Recording

Will the media cover this event?: (required)

Amount of people expected: (required)

CONTENT

Type of Speech: (required)
 Informational / Educational Message Sermon / Khutbah Debate Emcee / Facilitator Training Workshop Inspirational Message Other

PowerPoint screen & projector will be available: (required)
 Yes No

Topic(s) Requested: (required)

Goal for Speech or Message: (required)

LOGISTICS

Contact Person Handling Logistics: (required)

Phone Numbers: (required)

Email: (required)

TRAVEL

Transportation & accommodations expenses provided?: (required)
 Gas Rental Car Train Fare Air Fare Hotel Accommodation Meals None

HONORARIUM

 Yes No

All speech requests will be confirmed or declined by e-mail.

If you have any questions please contact;
Ali Erman
Phone: 516-359-7053
Email: aeeyuboglu@gmail.com