Speaking Request: Middle Georgia State University

Speaking Request

Speaking requests must be received at least 30 days prior to the event. Requesting person will be contacted within five business days of receipt of request.

Name of person making request:*
Department/Organization:*
Phone:*
Email:*
Name of event:*
Date of event:*
Event start time:*
Event end time:*
Location of event:*
If Dr. Blake is not available, would you like the Provost, one of our Vice Presidents, a Dean, a Department Chair, or a Director to offer remarks?:*	Yes No
Type of remarks required:*	Keynote speaker Welcome Remarks
Suggested length of remarks:*
Name and title of person introducing Dr. Blake:*
Who is the audience?:*
Expected number of attendees:*
VIPs to be recognized in remarks:
Additional information (Please include detailed talking points that Dr. Blake is requested to cover in these remarks. Note that the amount of content provided should correspond to the length of the remarks requested.):*