ACLU Speaker Request Form

Thank you for your interest in having Anthony Romero speak at your event. In order to help facilitate your request, please complete and submit the following form at least two months prior to the event.

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Part 1: Event Organizer

Name of Organization Submitting Request:

Event Sponsor(s):

Coordinator / Point of Contact:

Name, title, email, office phone, cell phone

Part 2: Event Details

Event Name / Title:

Event Location:

Event Date / Time:

Event Type:

Conference, dinner, small group, etc.

Event Purpose / Goal:

Event Website:

If applicable

Part 3: Presentation / Speech Details

Requested Topic:

Presentation Format:

Keynote address, roundtable, panel, award presentation, etc.

Expected Duration of Anthony's Remarks:

30 minutes, 1 hour, etc.

Part 4: Audience Details

Audience:

Approximate size of audience. Also briefly describe its make-up and if membership is required to attend.

Honorable Guests:

List names and titles of members of Congress, CEOs, or other VIPs participating in, or attending the event.

Media:

Will media be invited? If so, will the event be open or closed press? Also describe and submit media list.

Part 5: Additional Information

Deadline for Acceptance:

Would you accept another ACLU representative if Anthony is unavailable:

Cost of Attendance:

Please include member and non-member price, if applicable

Offer of Payment / Reimbursement:

None, dining, lodging, travel, honorarium

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