Speaking Engagement Request Form

Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send.

Any field marked with a red astrerisk (*) are required

Requester / Organizer

Contact Name *

Phone Number *

Email *

Alternate Name

Alternate Phone Number

Alternate Email

Information About Requesting Organization

Name of Organization *

Organization Website

Description of Organization *

Information About Event

Event Title *

Start Date *

Start Time *

End Time *

End Date *

End Date Start Time *

End Date End Time *

Event/Registration Website *

Registration Fee *

Open to the Public *

Enter fee amount *

Venue *

Address (Street, City, State, Zip) *

Description of Event *

Audience Size *

Primary Language of Expected Audience *

Audience Type *

Community
Govt. Agency
Legal / Professional

Other Audience Type

Audience Knowledge of Topic (limited / knowledgeable / very knowledgeable)

Agenda / Schedule Available for Event

Yes (if yes, please provide a copy to speaking.engagements@dfeh.ca.gov)
No

Speaker and Participation Details

Requested Speaker (if known)

Speaker Participation Format (keynote speaker, panel member, etc.) *

Speaker Participation Date and Time *

Date

Time

Speaker Length of Participation *

Topic of Presentation (Select from Dropdown Menu) *

Please add more information about the training being requested if necessary

Photo Needed *

If yes, due date needed

Biography of Speaker Needed *

If yes, due date needed

Audio / Video / Materials Needed *

If yes, due date needed

Will you need a master copy of speaker's handout / material prior to the event for reproduction and distribution (The master copy(s) will be sent electronically as a pdf)? If yes, due date needed

Travel Information

Recommendation(s) for hotel accommodations that provide government rates

Hotel Name #1

Phone Number

Hotel Name #2

Phone Number

Closest Airport to the Event

Map / Direction from the Airport to the Hotel and Event Location

On-Site Contact During Event

Contact Name *

Email *

Phone Number *

Fax Number

Today's Date

Today's Date *

Phone

NOTE: CRD staff cannot accept speaker fees, honorariums, or travel expenses. The external host may waive the speaker's registration or conference fees.

651 Bannon Street, Suite 200
Sacramento, CA 95811
Regional Offices

800-884-1684 (voice), 800-700-2320 (TTY) or
California's Relay Service at 711
contact.center@calcivilrights.ca.gov