Speaker's Bureau Request Form

The Center for Self-Development, LLC

Speaker's Bureau Request Form**

2 Pidgeon Hill Drive, Suite 450

Sterling, VA 20165

Office 703.433.1553 Fax 703.433.1558

Name of Organization: ______________________________________ Date of request:_______________

Address: _______________________________________________________________________________

city state zip

Phone Contact: ____________________________________ Phone Number: ________________________

name

Affiliation with the organization: ___________________________________

Reimbursement: $_______________

Topic of Interest:

_____What is stress and how to manage it

_____Relaxation techniques

_____Communication skills

_____Good mental health

_____Dealing with insomnia

_____Substance abuse

_____Anger management

_____Is drinking a problem?

_____Depression: What is is and what it is not and when to get help

_____Aging parents and impact on the family unit

_____Other: _____________________________________________________

Date of the Event: ___________________ Time of the Event: ____________________

Location of the Event: _______________________________________________________________________

________________________________________________________________________

city state zip

Duration of Presentation: ___ 30 minutes ___ 60 minutes ___Other _________

Format: ____ interactive _____ educational _____ question and answer

Audio/visual Equipment available: ____ overhead ____ computer ____ projector ____ viewing screen

Audience: ____ men ____ women ____ mixed Group Membership: ________________________________

Racial and cultural background: ____ Caucasian ____ African American ____ Mixture

Education Level of Participants: ___ high school grads ___ college students ___ college grads ___ unknown

Career level of audience: ____ lay community/general public ____ professional ____ employer ____ employee

Ages of audience: ____ 18-25 ____ 25-35 ____ 35-45 ____ 45-55 ____ 55-65 ____ 65 and older

What are your goals for this presentation?

__________________________________________________________________________________________

** Link to PDF

Fax completed form to:

The Center for Self-Development, LLC

Fax: 703.433.1558