Speaker Request

To request a speaker for your organization or group,
please print this form, fill it in, and mail to:

The B.A.R.K. Plus Chapter of the ACLU of Northern CA
?
Berkeley, CA ?

You and Your Organization:

Your Name: ____________________________________________

Daytime phone: ________________Evening phone: _____________

Organization Name: ______________________________________

Please specify the purpose of your organization:

______________________________________________________

______________________________________________________

Speaking Engagement Details: (At least 3 weeks advance notice.)

Preferred Date:___________________________________________

Alternative Date (1):____________Alternative Date (2):____________

Start Time:___________________Time Allotted For Speech:_______

Where the speaking engagement will be held:

Address:________________________________________________

_______________________________________________________

_______________________________________________________

The subject of the requested talk:

_______________________________________________________

_______________________________________________________

Who will introduce the speaker?

Name:__________________________________________________

Daytime phone: ________________Evening phone: _____________

Any additional questions or comments you may have:

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________