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Click here for an electronic version of this form.

REQUEST FOR SPEAKING ENGAGEMENT
WITH TIMOTHY DIMOFF

Name of Organization:	__________________________________________________
Contact Person:	__________________________________________________
	Address:___________________________________________
	City:_______________________ State:______ Zip:_________
	Phone: (_____)_____________ Fax: (_____)______________
	E-mail:  ___________________________________________
Title of Event:	__________________________________________________
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