Date:

Name:

Title:

Organization:

Address:

City:     State:    Zip Code:

Work Phone: / Fax: / Mobile:

Email:

Website:

Name of Event:

Purpose of Event :

Dates of Event:

Group to Speak To :

Times for Darlene to Speak:

Place:

Describe the Nature of the Event (purpose, themes, goals, etc...)

Is it a workshop setting?    Platform / general session

Number of People Expected    Age, Needs, etc.

Budget alloted for speaker

Date and Time Darlene is to Arrive:

What is your role with planning this event:
Decision Maker Event Planner Committee Member Interested Party Other

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