Speaker Request Form To submit a Speaker Request for Mustafa Santiago Ali, please complete this form.Upon receipt of a completing form, we will respond within 7 Business Days with a response or a request for additional information, as required. Thank you! Speaker Request Form Event Information Organization Event Title Type of Event ConferenceTrainingClassBanquet Panel DiscussionSeminarOther Type of Event Function at Event Keynote, PanelistModeratorGuest LecturerTrainerOther Function at Event Event Date Start Time 121234567891011 : 0030 AMPM End Time 121234567891011 : 0030 AMPM Event Location Anticipated # of Attendees Target Audience Suspense Date *Deadline Response Required to Confirm Speaker Event Background Objective of Event What is the objective of this event? Desired outcome of this event What is the desired outcome and impact you want this event to have? Agenda of this event What is the planned agenda and timeline for this event? Speaker Information Topic to be discussed Speech Length Honorarium Amount : $ Honorarium Range : $5000 – $25,000 Desired outcome Speaker What is the desired outcome /impact do you want this speech to have on the audience? Special details for the speech Media coverage If there will be media coverage, who do you plan to receive media coverage from? Travel Arrangements The requesting organization is responsible for covering the costs of roundtrip airline/train transportation, hotel and all applicable ground transportation costs for Dr. Mustafa Santiago Ali to attend this event. Will you book his travel? Yes No Will you book travel and you reimburse the cost? Yes No Required Arrival Date Required Arrival Time 121234567891011 : 0030 AMPM Travel Contact Name Who should Out-of-Pocket Travel Receipts be sent to for reimbursement? Travel Contact Phone Number Contact Email Address Contact Billing Address Invoice Payment Point of Contact Please provide the Invoice Payment Point of Contact responsively for processing I voice payment and or travel reimbursements, as applicable. Contact Name Contact Phone Number Contact Email * On-Site Point of Contact Please provide the Contact that will be available to assist with any travel arrival or logistical issues, if they arise. Contact Name Contact Phone Number Contact Email * Attachments Please attach the Flyer, Agenda, Run-Of-Show and/or any additional information supporting the planned timeline for this event. Attachment Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 104.86MB Submit Δ