Form

CTV Speaker Request Form
Contact Name*
Group Name*
Event Sponsor
Address Line 1*
Address Line 2
City*
State*
Zip*
Email*
Phone*
Date of Event*
- Month - Day Year
at
/ Hour Minutes
Date Requesting (list no more than 3 options)
Type of Event*
SPEAKER/SUBJECT
Purpose of Event*
Speaker I am Requesting...*
Desired Topic*
Speaker would be ...*
Event Time
Speaker Start Time
Time Allotment for Speaker
Estimated Attendance
Other (regarding Speaker)
...
VENUE INFORMATION
Venue: Physical Address*
Venue Phone*
Venue Additional Information (i.e. which entrance)
OTHER
Honorarium negotiable*
Further Thoughts/Questions
If you have any questions after submitting this form, please contact us at 517-321-1390 or ctv@ctvmichigan.org. We thank you for this invitation and look forward to talking with you soon!
Should be Empty:

CTV Speaker Request Form