Oklahoma Wesleyan University

Part 1: Event Organizer
Name of Organization *
Event Sponsor(s)
(if in addition to Event Organizer)

Please list any additional sponsors of your event
Type of Organization *
Part 2: Coordinator/Contact Person

Please complete the information below so we can contact you about your request.
Name * First Last
Title of Contact Person *

What is your role in relation to this organization or event?
Email *
Phone Number * ### - ### - ####
Part 3: Event Details
Event Name *
Date of Event * MM / DD / YYYY
Event Start Time * HH : MM : SS AM/PM
Estimated Start Time of Speaking Slot * HH : MM : SS AM/PM
Event Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Event Type (conference, dinner, small group, etc.) *
Event Purpose (optional)
Event Website (if applicable)
Part 4: Presentation Details
Expected Duration of Presentation *
Presentation Format
(Keynote address, round table, panel, etc.) *
Preferred Topic of Speech (select any that apply) *
First Choice Second Choice Third Choice Fourth Choice Fifth Choice Sixth Choice
Will a question and answer (Q&A) time follow the presentation? *
Part 5: Audience Details
Audience Size *
10-50 Audience Members 50-100 Audience Members 100-300 Audience Members 300-500 Audience Members 500+ Audience Members
Audience Profile (Check All that Apply) *
High School/College Aged Adults Church Members Educators Pastors Other (please describe)
Additional Audience Profile Information *
Will members of the press be present? *
Describe/Submit Media List *
Additional Information
Deadline for Acceptance * MM / DD / YYYY
Will a photo/bio of Dr. Piper be needed? *
Speaker Fees and Reimbursement
(Check any that apply) *
Honorarium Offered Travel Reimbursement Provided Lodging Reimbursement Provided Other
Additional Speaker Fees/Reimbursement Comments *
Additional Notes
Assignee
Do Not Fill This Out

Oklahoma Wesleyan University

Part 1: Event Organizer

Part 2: Coordinator/Contact Person

Part 3: Event Details

Part 4: Presentation Details

Part 5: Audience Details

Additional Information