Name of Primary Contact
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Name of senior pastor, if applicable
First Name
Last Name
Address of your organization/business/church:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of event:
*
MM
DD
YYYY
Time speaker(s) needs to arrive:
Hour
Minute
Second
AM
PM
Length of speaking time and time speaker begins:
*
What event topics/workshops are you interested in?
*
Will the speaker(s) be requested to speak at multiple sessions?
*
Do you have a speaker budget?
*
Would Action169 be able to set up a table with resources, books, and merchandise?
*
If Action169 is allowed to set up a table, would the table be provided?
Churches & faith groups: Will you be receiving an offering for Action169?
Funds received during an offering will go directly towards Action169 vision and mission and not to the speaker.
Will a hotel be provided?
If the event is more than two hours from requested speaker and requires driving in the evening, or is more than one day, please indicate below if hotel accommodations can be made.
Will flights be provided?
Are you able to provide flight accommodations if such is required? Most of the Action169 speakers reside in either Central MN, Southern MN and Northern IA.
Will the event be filmed? How will footage be used?
Do you need promotional materials?
We can email you the Action169 logo and any needed headshots of our speaker(s).
Notes, Questions or Additional Information:
Is there anything you would like for the speakers to know?
