Speaker Request Form

Please complete the following form to request a speaker or presentation from Kansas Tourism. All questions should be directed to Jaimee Salalac, Jaimee.Salalac@KS.gov, or 785-296-2009

Contact Information

Organization Name:

First Name*:

Last Name*:

Email:

Primary Phone:

Additional Contact Information

Contact Person at Site*:

On Site Contact Phone Number*:

On Site Contact Email*:

Event Information

Name of the event*:

Requested Speaker*:

Who are you requesting to speak?

Event Date*:

Event Time*:

Number of people attending*:

Location of Event*:

Exact Speaking Time*:

Presentation Details

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Presentation Type

Keynote or Main Speaker
Discussion Panel
Brief Remarks
Presentation
Welcoming Speaker
Appearance Only
Drop By

Speech Topic/Comments*:

Time for Q&A?*:

Yes No

Slides Needed?*:

Yes No

Are slides requested or desired for the presentation?

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Please mark all that will be available.

Microphone
Podium
Computer/Laptop
Projection Screen

Additional Information & Special Requests:

* Indicates a required field.

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Speaker Request Form

Contact Information

Additional Contact Information

Event Information

Presentation Details