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2023 Leadership Speaker Request Form
*
Form submitted by:
*
Date submitted:
*
Phone:
*
Email:
*
Company:
*
Event Date:
*
Event Time:
*
Coordinator:
*
Phone Number:
Tocqueville prospects ($10,000)
Yes
No
Builder prospects ($5,000)
Yes
No
CEO present:
Yes
No
Who will cover matching programs (choose one):
Coordinator
LE
Major Gifts (preferred)
Audience profile (check all that apply):
Male
Female
Administrative
Manufacturing
Professional
Medical
*
Address/location of meeting:
What type of speaker are you requesting?
Financial Services
Education
Health
General
UWCA Staff
Gender:
Male
Female
*
Speech length:
Speaker attire:
Business
Business Casual
Casual
*
Number of attendees:
Additional Notes:
Items marked with an asterisk(*) are required
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