Speaker Request Form

Event Details

Event Title

Is the speaking engagment in-person or virtual?(Required)

In-person

Virtual

Either

Speaking Date(Required)

Time(Required)

:

Time Zone(Required)

Is the date/time flexible for when the speaker(s)/panelist(s) speak?(Required)

Yes

No

Location(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Event Information

Hosting Organization(Required)

Background or purpose of the event(Required)

Inform the purpose, content and goals of the event to potential attendees

Proposed Speaker Role(Required)

Other(Required)

Do you anticipate audience Q&A's?(Required)

Yes

No

Expected number of attendees(Required)

Composition of the audience (e.g. patent attorneys, academics, business executives, federal employees, inventors, policymakers, students, NAI chapter members, etc.)(Required)

What is the audience's expected level of IP knowledge?(Required)

Is the media expected to be in attendance?(Required)

Yes

No

Will the presentation be recorded or made public?(Required)

Yes

No

Is there any attendance fee?(Required)

Yes

No

Fee amount(Required)

If travel expense(s) are being offered, please indicate the nature of the expense.

Expense type

Amount

For example, ground travel, airline, hotel, meals, etc.

Requester Contact Information

Name(Required)

First Last

Title

Organization(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

How did you hear about this program?

Other

Are you the event point of contact?(Required)

Yes

No

Event Point of Contact

Event Point of Contact(Required)

First Last

Phone(Required)

Email(Required)

Speaker Request Form

Event Details

Speaker Information

Event Information

Requester Contact Information

Event Point of Contact

Mailing Address

Email

Phone

Sponsor

Social