LifeWorks Speakers Bureau Request Form

LifeWorks Speakers Bureau Request Form (* Indicates required field.)

It is recommended that you request 6 to 8 weeks in advance of your event.

Requested Speaker: Douglas Kuhns

Requestor Contact Information

* First Name:
* Last Name:
* Telephone Number:
* Email Address
* Verify Email Address
* Organization or School:
* Organization or School City:
* Organization or School State:

Presentation Information

* Event Location Address:

* Event Location City:

* Event Location State:

* Event Location ZIP Code:

* Topic

* Length of Presentation:

(example: 20 minutes, 30 minutes, 1 hour, etc.)

Type in or select the date and time (and alternative options) for the event

* Preferred Date and Time:

Date:
Time:

(MM/DD/YYYY, example 1/31/2001)

(HH:MM AM/PM, example 3:00 PM)

Alternate Date and TIme 1:

Date:
Time:

Alternate Date and Time 2:

Date:
Time:

Audience

Approximate Age Range of Audience:
Scientific Background of Audience With Respect to Topic:
Number of Persons Expected to Attend:

Additional CommentsEnter additional comments or details about event, up to 200 characters