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REQUEST FOR SPEAKING ENGAGEMENT
WITH TIMOTHY DIMOFF
| Name of Organization: | __________________________________________________ |
| Contact Person: | __________________________________________________ |
| Address:___________________________________________ | |
| City:_______________________ State:______ Zip:_________ | |
| Phone: (_____)_____________ Fax: (_____)______________ | |
| E-mail: ___________________________________________ | |
| Title of Event: | __________________________________________________ |
| Name & Cell Phone Number of the on-site contact person: | |
| Name: ____________________________________________
Cell Phone: ________________________________________ |
|
| Proposed dates and times requested: | |
| 1st Choice: Date:___________________ time:______________ |
|
2nd Choice: Date:___________________ time:______________ |
|
3rd Choice: Date:___________________ time:______________ |
|
| Location of Event: | __________________________________________________ |
| Address: | __________________________________________________ |
| City:_______________________ State:______ Zip:_________ | |
| Topic Desired: | __________________________________________________ |
| Length of Time: | _________________ |
| Number of People Expected: | _________________ |
| Is there a flip chart and/or marker board available? ______ Yes ______ No | |
| Is there an overhead/screen available? ______ Yes ______ No | |
| Is there a powerpoint projector available? ______ Yes ______ No | |
| Is there a laptop available? ______ Yes ______ No | |
Additional comments or requests: |
|
*PLEASE FAX OR MAIL A MAP, ALONG WITH THIS FORM, TO:
Mr. Tim Dimoff • 520 South Main Street
Canal Place-Suite 2512 • Akron, Ohio 44311-1010
Phone: (330) 255-1101 Fax: (330) 255-1135