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Speaker Request Form
Thank you for your interest in having someone from MASS speak at your event. Please fill out this form to provide us with additional information.
Name of event
Organization
Your name
Your title
Your e-mail address
Your phone number
Type of request
Conference
Keynote
Lecture
Panel
Workshop
Other…
Enter other…
Location
Date of event
Expected time commitment
Event description
Who will be in the audience?
Size of audience
< 50
50-100
100-300
300-500
500-1000
1000+
Event website (if applicable)
Requested speaker
Would you be open to someone else?
Yes
No
Why MASS? What perspective would we add to the event?
Is there an honorarium?
Yes
No
Amount?
Expenses covered? (check all that apply)
Travel
Lodging
Food
No Expenses Covered
Anything else we should know?
