Va Form 0879 - Speaker Request Form

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SPEAKER REQUEST FORM
THE CENTER FOR WOMEN VETERANS (CWV)
NOTE: Due to the volume of requests for speaking engagements, outreach and development, CWV asks that you complete the entire
form below. Please note that six to eight months is most desirable to accommodate speaker calendar requests. Completion of this form
will assist in expediting a timely response. If you have any additional inquiries, please contact CWV at (202) 273-6193 or visit us at :
SPEAKER REQUESTED
DR. IRENE TROWELL-HARRIS, DIRECTOR
OTHER (Identify below)
BETTY MOSELEY-BROWN, ASSOCIATE DIRECTOR
HOST ORGANIZATION INFORMATION
NAME OF ORGANIZATION
MAILING ADDRESS
POINT OF CONTACT
ORGANIZATION WEBSITE ADDRESS
POSITION WITHIN ORGANIZATION
E-MAIL ADDRESS
DAYTIME PHONE NUMBER
EVENING PHONE NUMBER
FAX NUMBER
EVENT LOGISTICS
NAME OF EVENT
VENUE LOCATION (Mailing address, venue room number, etcetera)
DATE OF EVENT
TIME
TYPE OF EVENT (e.g., Recognition Ceremony, Luncheon, Health fair, etcetera)
TYPE OF SPEECH (e.g., Keynote, panel participant, lecture, etcetera)
SPEAKING POINTS (Please include event theme and purpose)
AUDIENCE INFORMATION
TYPE OF AUDIENCE (e.g. women veterans, military, civic organization, public/private sector, etcetera)
EXPECTED NUMBER OF ATTENDEES
SPECIAL GUEST ATTENDEE(S)
0879
VA FORM
SEP 2006

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