Speaker Request Form

Thank you for you inquiry about Bob and/or Cheryl Reccord speaking at your event. This form helps us as we pray and make final decisions concerning the speaking schedule. Our policy is that until we receive all information and the "$"500 deposit, the date is not solidified on our calendar.

Please feel free to contact our office if we can be of further assistance. Email: Info@totallifeimpact.com or call 770.662.7082.

Date *

Select requested speaker *

Organization Name

Contact/Organizer *

Contact - Mailing Address *

City *

State *

ZIP *

Phone Number *

Cell phone

Fax

Email *

Event Name

Event Description *		Please provide an overview of the event.

Event Location & Address

Event Phone

Event Start Date *

Event End Date *

Speaking Times *		Please provide the times you need the speaker to be present for this event. If there is a specific arrival time needed, please note that as well.

Projected Attendance *

Attendance at last event *

Other Speakers *

Topic Requested

If "other", please provide details:

Dress for event *

Audio/Visual Support	Audio - we have headset capability Video capability - we can connect your computer to our system Video capability - we need a CD of PowerPoint to run on our system We are unable to offer PowePoint Please call us to discuss	Please select all that apply.

Audio/Visual Contact Information

Can we sell books at this event?	Yes No

If "yes," please provide shipping address information.

Book table - guidelines

Nearest Airport *

Transportation Preference	We will pick Bob and/or Cheryl up at the airport Please have them get a rental car and we will reimburse them.

Website Link		We would like to link to your event from our website at www.TotalLifeImpact.com. If you are able, please link your website to ours as well. Thanks!

Honorarium Amount *

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Speaker Request Form