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2023 Agency Speaker Request Form
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Today's Date:
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UW Staff manager:
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Loaned executive or person making request:
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Work phone:
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Cell phone:
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Email:
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Company where speech will be held:
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Company coordinator or other contact person:
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Work phone:
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Coordinator's email address:
Audience profile:
Male
Female
Administrative
Manufacturing
Professional
Type of meeting:
Virtual
In Person
If virtual, what platform will the meeting be on?
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Date of meeting:
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Time:
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Number of expected attendees:
Do you have additional dates and times?:
Yes
No
Date of meeting:
Time:
Number of expected attendees:
Date of meeting:
Time:
Number of expected attendees:
Date of meeting:
Time:
Number of expected attendees:
Date of meeting:
Time:
Number of expected attendees:
Date of meeting:
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Number of expected attendees:
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Number of expected attendees:
Date of meeting:
Time:
Number of expected attendees:
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Meeting room address, directions and parking instructions:
Speech Length:
Speaker attire:
Business
Business Casual
Casual
Theme of speech: (Select one of the following from United Way's four focus areas:)
Education/ Early Learning/ Helping Children Succeed
Income/ Financial Stability/ Strengthening Families
Health/ Improving Health/ Fitness
Access To Services/ Disaster Response
No preference
Requested Agency 1:
Requested Agency 2:
Requested Agency: 3
Additional comments:
Items marked with an asterisk(*) are required
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