Speaking Engagement Request Form

Date of Request*

Date of Function*

Organization*

Contact Name*

Email*

Phone*

Function

Theme/Topic

Location

Audience (size, age range, etc.)

Number/length of messages

Function Schedule

Time Dr. Agron will speak

Dress code

Book Sales Table ApprovedDenied

Will function be recorded? NoYes (audio)Yes (video)
If Dr. Agron's material is recorded, • Dr. Agron grants permission for your internal use and distribution (e.g., copies given or sold to church members but not sold online or at other venues) • Dr. Agron must receive a copy that can be reproduced and use with full rights

Compensation

Accommodations

Meals

Transportation

Method/Time of payment

Any additional information you need from Dr. Agron