Speaker Request Form

Official Speaker Request Form

* Please note that this form must be completed within 14 days before actual scheduled event for processing and to ensure participation.
For additional information or to speak with someone directly contact Scott Haggard (Government & External Affairs Director)
404.893.2055 | shaggard@gamobility.info *




Will the event be indoors or outdoors?
IndoorsOutdoors
Do you have any presentation needs?
BioPhotoBusiness CardsInformational PublicationsPowerPoint Presentation


Primary Event Contact Person


Alternate Event Contact Person


Local Media Contact Person


What type of event?

What is the role of the speaker at the event?
Featured speakerWelcoming remarksForum or panel speaker

Please provide details about the group/audience that would be helpful to the speaker

Please provide list of key issues of importance to the organization and/or specific issues that the group would like the speaker to address.

Please list other officials or special guests to attend, including name/titles.

Estimated number of attendees

Is the event open to the public?
YesNo

Will the media be in attendance?
YesNo

Who else will be speaking? Please include names/titles

Approximate time the speaker will be introduced to speak.

What takes place immediately before and after the speaker speaks?

Who will introduce the speaker? (name/title)

Who will be seated with the speaker? Please include names/titles.