Speaker Request Form

Who: (Name of your organization, identify website, social media sites)

Where: (include physical address, name of building, floor, entrance to use & identify if there is construction in the area and possible detours. Be sure to identify if the event is an outdoor venue.)

Proposed Dates: (preferred date & a secondary date, if possible)

Time: (include time you wish Mrs. Fleming to arrive, what time she is to speak, the length of time allotted to her commentary and time allotted for Q&A, if any.)

Type/Purpose of Event: (specify luncheon, dinner, rally, regular meeting, annual event, fundraiser, etc. and give a description of your event’s purpose or theme)

Audience: (please estimate attendance; give a short description of the audience – new to this topic or seasoned activists or a mixture? Do elected officials regularly attend? If so, identify if local, state and/or Congressional)

Media: (will media be present? If so, which newspaper, radio, television, or online publications?)

Cell phone contact info for day of the event: (please identify a person who will answer texts or phone in an emergency)

Speaker accommodations: Will a table be available for materials? Speaker accommodations: Will a table be available for materials? Yes No

Will a screen, projector, laptop & operator be set up for Power Point presentation? Will a screen, projector, laptop & operator be set up for Power Point presentation? Yes No

Will a podium be provided? Will a podium be provided? Yes No

Will the microphone be hand-held or a lapel mic? Will the microphone be hand-held or a lapel mic? Yes No

Will the meeting be video-recorded? If so, do you have a recording release form Mrs. Fleming should review before signing as a release/waiver of her rights?

Will your organization contribute to offset speaker’s travel expenses? She resides south of Tyler, TX. Mrs. Fleming is a full-time volunteer and does not charge an honorarium; however, we appreciate assistance with her considerable lodging and travel expenses (mileage). Mrs. Fleming cannot accept checks made out to her personally. Please make contributions to Grassroots America – We the People PAC Will your organization contribute to offset speaker’s travel expenses? She resides south of Tyler, TX. Mrs. Fleming is a full-time volunteer and does not charge an honorarium; however, we appreciate assistance with her considerable lodging and travel expenses (mileage). Mrs. Fleming cannot accept checks made out to her personally. Please make contributions to Grassroots America – We the People PAC Yes No

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