Agency Speaker/Tour Request Form

In order to ensure your speaker/tour experience is positive, ALL fields with an asterisk(*) are required fields and need to be completed. If information does not apply, please type N/A in that field.

*Today's Date: *Event Date:
mm/dd/yyyy

Workplace Name:

*Workplace Branch/Department/Business Unit:

*Event Start Time:    *Event End Time:

*Speaker Arrival Time:    *Speaker Start Time:

*Speaker Presentation Length:
3-5 minutes
5-7 minutes
7-10 minutes
10-15 minutes
Other

*United Way DVD/Video to be played?    YesNo
*DVD/Video player available at the location?    YesNo
*Workplace Contact Name:

Workplace Contact Title:

*Workplace Address:

*Workplace Contact Phone Number: Ext:

*Workplace Contact Fax:

*Workplace Contact Cell Phone Number (for event day only):

*Workplace Contact Email:

Workplace Website:

In case the Workplace Contact is unavailable, please provide Alternate Workplace Contact:

*Alternate Workplace Contact Name:

*Alternate Workplace Contact Phone Number:

Alternate Workplace Email Address:

Alternate Workplace Cell Phone Number:

*Event Address:

*Building Name/Floor/Department/Room:

*Event Directions:

*Event Parking:

*Event Entry Procedures:

*Event Security Procedures:

*Audience Size:

*Audience Description/Demographics:

Comments:

United Way Liaison, if known:

Complete this section only if you wish to request a specific interest area or speaker.

Specific Interest Area:
Education: Ensuring success for children in school and in life
Income: Helping lower-income families become more financially stable
Health: Providing a safety net of health and human services for all

*Is this an agency fair?    YesNo
*Is this a leadership event?    YesNo