To request a speaker for Disaster Preparedness or Weather related topics, please fill out the request form below and fax to 910-643-8570.

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Contact information of person requesting a speaker:

*

First Name:

*

Last Name:

*

Organization:

*

Primary Phone Number:

Ext.:

Alternate Phone:

Ext.:

*

E-Mail Address:

 

Event Name and Address:

 

*

Event Name:

 

*

Event Address:

 

 

*

Purpose of Event:

 

*

Event Date:   (mm/dd/yyyy)

Date Selector

 

*

Event Start Time: (hh:mm)

    (local time)

*

Speaker Start Time: (hh:mm)

    (local time)

Building or Room:

 

Topic Requested:

Speaker Requested (if known):

*

Expected Audience Size:

 (numbers only)

*

Audience Description:

Total Time Allotted (Speaker):

Q&A included?

 

 

Event Open to the Press?

If yes, please provide details:

Event to be Broadcast?

If yes, please provide details:

Speech to be Taped?

Speaker bio needed?

Speaker photo needed?

 

 

Indicate Equipment Available

 

Lavaliere or Lapel Microphone                                                                                  

LCD Projector

DVD

Player

Room can be darkened

 

Public Address System

Computer with Presentation Software

VCR

 

 

 

 

 

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