MGI Speaker Request Form

ORGANIZATION NAME*

TITLE OF EVENT

TOPIC(S)

EVENT LOCATION

EVENT DATE

TIME

URL OF EVENT WEBSITE

TELL US A LITTLE ABOUT THE CONTRIBUTION THAT YOU WOULD LIKE THE MGI SPEAKER TO MAKE: E.G. PANEL MEMBER, KEYNOTE SPEECH, ROUNDTABLE*

DURATION OF MGI PRESENTATION: (30 MINUTES, 1 HOUR, ETC.)

WHAT IS THE EXPECTED AUDIENCE FOR THE EVENT?

Private Sector (C-suite)

Public Sector

Academic/Think tank

Private Sector (other)

Social Sector

Students

IS THIS EVENT OPEN TO MEDIA?*

YES

NO

WILL IT BE ON THE RECORD?*

YES

NO

WILL THE EVENT BE RECORDED ON VIDEO?*

YES

NO

WILL THE EVENT BE STREAMED LIVE?*

YES

NO

WHO ARE THE SPONSORS OF THE EVENT, IF APPLICABLE?

ARE ANY OTHER ORGANIZATIONS ENGAGED IN THE EVENT? IF SO, PLEASE LIST AND INCLUDE DETAILS OF INVOLVEMENT?

NAME*

JOB TITLE*

EMAIL*

TELEPHONE

*