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Click here for a fax-ready version of this form.


REQUEST FOR SPEAKING ENGAGEMENT
WITH TIMOTHY DIMOFF

Name of Organization:
Contact Person:
Address:
City, State, Zip:
Work Phone: Fax:
Mobile Phone:
E-mail:

Title of Event:

Proposed dated and times requested:
1st choice:  Date:  Time:
2nd choice:  Date:  Time:
3rd choice:  Date:  Time:

Location of Event:
Address:
City, State, Zip:

Topic Desired:

Length of Time:
Number of People Expected:

Is there an overhead/screen available?: Yes No

Is there a flip chart and/or marker board available?: Yes No

Is there a powerpoint projector available?: Yes No

Is there a laptop available?: Yes No

Additional comments/requests:


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