Jess Legaspi Speaking Request Form

First Name	Last Name
Title:	Organization Name:
Phone number	E-mail
Street Address	City
State/Province	Zip/Postal Code

Event Details

Event Name

Event Sponsor/Organizer

Type or Organization

Other

Event Start Date & Time

Date

Hour

Minutes

Time of Day

Event End Date & Time

Date

Hour

Minutes

Time of Day

Full Event Address

Additional Information: For example: table number and location, name of building, location within a park).

Event Venue/Event Type/Event Attire

Venue

Event Type

Attire

Event Type (Other)

Attire (Other)

Event Description

Event Size and audience composition

Will media be present?

If yes, please specify

Dignitary and community leader invitees (click below to add additional responses)

Dignitary/Community Leader Name

Title/Organzation

Confirmed?

Participation Information

What would Jess Legaspi's role be at the event?

If Jess is speaking, what time and for how long?

Time

Time of Day

How Long?

Who will introduce Jess?

Speaking Area

Speaking area (other)

What topics would you request Jess cover in her remarks?

If Jess is unable to attend, would you accept any of the following (check all that apply):

VideoStaff Representative

Please attach any related event information:

Contact Information

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