SPEAKER REQUEST FORM
THE CENTER FOR WOMEN VETERANS (CWV) NOTE: Due to the volume of requests for speaking engagements, outreach and development, CWV asks that you complete the entire form below. Please note that six to eight months is most desirable to accommodate speaker calendar requests. Completion of this form will assist in expediting a timely response. If you have any additional inquiries, please contact CWV at (202) 273-6193 or visit us at : http://www.va.gov/womenvet.
SPEAKER REQUESTED DR. IRENE TROWELL-HARRIS, DIRECTOR BETTY MOSELEY-BROWN, ASSOCIATE DIRECTOR OTHER (Identify below)
HOST ORGANIZATION INFORMATION
NAME OF ORGANIZATION MAILING ADDRESS
POINT OF CONTACT
POSITION WITHIN ORGANIZATION
ORGANIZATION WEBSITE ADDRESS
E-MAIL ADDRESS
DAYTIME PHONE NUMBER
EVENING PHONE NUMBER
FAX NUMBER
EVENT LOGISTICS
NAME OF EVENT
DATE OF EVENT
TIME
VENUE LOCATION (Mailing address, venue room number, etcetera)
TYPE OF EVENT (e.g., Recognition Ceremony, Luncheon, Health fair, etcetera)
TYPE OF SPEECH (e.g., Keynote, panel participant, lecture, etcetera)
SPEAKING POINTS (Please include event theme and purpose)
AUDIENCE INFORMATION
TYPE OF AUDIENCE (e.g. women veterans, military, civic organization, public/private sector, etcetera)
EXPECTED NUMBER OF ATTENDEES
SPECIAL GUEST ATTENDEE(S)
VA FORM SEP 2006
0879
Adobe Forms Designer 6.0