Speaker Request Form

JoAnn Fleming

Grassroots America’s
Executive Director & Chief Spokesman

Please be advised that our Executive Director’s daily workload is such that JoAnn is no longer available to speak for monthly meeting events that require 6 – 10 hours of roundtrip travel if you plan to allow her less than 30 minutes speaking time with 15 additional minutes for Q&A. Dedicating an entire day and the cost of travel for 15-20 minutes speaking time is something Mrs. Fleming can no longer accommodate. We will, however, work with you to send an outstanding substitute speaker from our organization.

Name of organization making request(Required)

Your website/social media(Required)

Address(Required)

Street Address City State ZIP Code

Meeting Location Instructions(Required)

Please include floor, meeting room number/name, building entrance identification or any other pertinent information to assist in finding your meeting location.

Proposed Speaking Dates(Required)

Please provide at least a first and second choice of available dates.

Speaker Arrival Time(Required)

Total Speaking Time(Required)

Length of time allotted for commentary(Required)

Time allotted for Q & A(Required)

Type/Purpose/Format of Event(Required)

Panel discussion, moderate a candidate forum, luncheon talk, dinner keynote, rally, regular meeting, annual event, fundraiser, etc.)

Describe your event's purpose or theme(Required)

Audience Details: Average Attendance?(Required)

Audience Profile: New? Seasoned activist? Mixture?(Required)

Does your US Congressman Attend? Identify(Required)

Do your State Legislators attend? Identify(Required)

Do local elected officials regularly attend? Identify(Required)

Media:(Required)

Will the media be present? If so, which newspaper, radio, television, or online publications?)

Contact information: Name & Cell phone(Required)

Person who will answer texts or call in the event of an emergency.

Contact information: Email Address(Required)

To send our speaker's biography.

Enter Email Confirm Email

Speaker Accommodations: Table(Required)

Will a table be available for materials?

Speaker Accommodations: A/V(Required)

Will a screen/projector/laptop & operator be set up & available for presentation?

Speaker Accommodations: Podium(Required)

Will a podium be provided?

Speaker Accommodations: Microphone(Required)

Microphone available? Hand-held or a lapel mic?

Speaker Accommodations: Video Recording(Required)

Will the meeting be video-recorded? If you do plan to capture our presentation in audio and/or video format, please send a Speaker Release Form, which identifies the purpose and use of your recording.

Travel Costs: Will your organization contribute to offset the speaker’s travel expenses(Required)

All of our designated speakers live in the Tyler area. We NEVER charge an honorarium. If your group cannot help with our travel expenses, we will NOT deny your speaker request; however, we are bound to take great care in how we spend our supporters’ funds and therefore must ask if your group can contribute. NOTE: Our speakers cannot accept checks made out to them personally. • Checks should be made out to Grassroots America – We the People. • All contributions are deposited into the GAWTP bank account, and a check is issued to the authorized speaker for full reimbursement of documented travel costs.

Anything Else We Should Know?(Required)

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Speaker Request Form

JoAnn Fleming

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