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 SpeakerCourse TeacherConferenceFundraiserSeminarOther

    Event Location (address): (required)

    Event date and time: (required)

    AUDIENCE

    Type of Audience (check all that apply):
    MaleFemaleMuslimsMembers of other faithsYouthAdults

    Will this speech be (check all that apply):
    Audio RecordedVideo RecordedTranscribedLive-StreamedNo Recording

    Will the media cover this event?: (required)

    Amount of people expected: (required)

    CONTENT

    Type of Speech: (required)
    Informational / Educational MessageSermon / KhutbahDebateEmcee / FacilitatorTrainingWorkshop Inspirational MessageOther

    PowerPoint screen & projector will be available: (required)
    YesNo

    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)
    GasRental CarTrain FareAir FareHotel AccommodationMealsNone

    HONORARIUM

    YesNo

    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