Request Type:	Invitation to Attend an Event Request to Provide Introductory Remarks or Welcome Guests Request to Deliver a Speech or Keynote
Name of Event:
Date of Event:
Time Event Starts:
Location of Event:
Brief Description of Event:
Contact Person:
Email Address:
Phone Number:	( ) - Second three digits Last four digits
Who Else is Invited to Speak at This Event?:
Who Will Introduce Dr. Gallagher?:
Is Dr. Gallagher the Keynote Speaker?:	Yes No
Topic of Speech Requested:
Requested Time Limit or Length of Speech:
Is This a PowerPoint Type Presentation?:	Yes No
Expected Number of Attendees and Composition of the Audience:
What Will the Room Configuration Be?:
Where Will Dr. Gallagher Be Speaking From?:	Will there be a podium, or raised stage?
Do You Need Dr. Gallagher's Biography?:	Yes No
Do You Need Any Photos in Advance?:	Yes No
Will Any Photos Need to Be Taken at the Event?:	Yes No
Will You Be Providing Bottled Water?:	Yes No
How Long is Dr. Gallagher Expected to Stay?:
Additional Notes or Information About the Event: