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
Part 6: Book Sales

Please complete if you would like to sell Dr. Piper's book at your event.
Would you like to sell Dr. Piper's book at your event?
Yes No
Name (Book sales contact) First Last
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

Part 6: Book Sales