College Speaking Event Request Form: Fill out the information below and press the "send your request" button to send. Contact Information: Mr. Mrs. Ms. Rev. Dr. First Name: Last Name: Telephone Number: 123-456-7890 Fax Number: E-Mail Address: Event Information: Date(s) you would like to have Dennis Marcellino speak and/or perform music: Year 2008 2009 2010 2011 Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Location of Event: (college, conference center, etc.): Address City: State: Choose a State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory Name of Event: Expected Audience Size: 0-50 50-100 100-200 200-400 400-600 600-800 800-1000 1000 or more FEES: Indicate amount in your budget for Dennis to speak and/or perform music at your event. Dennis Marcellino Speeches and Music: I am interested in these topics... Speech Topic #1: What Every College Student Needs to Know about Alcohol and Drugs Speech Topic #2: Self-Esteem Improvement for College Students Speech Topic #3: A “Major” Decision: Choosing the Right Major for You Music for Concerts and Events (without speech) Other Information: Special note or requests: . Please note that by requesting this information you are not obligated in any way.
College Speaking Event Request Form: Fill out the information below and press the "send your request" button to send.
123-456-7890
Year 2008 2009 2010 2011 Month January February March April May June July August September October November December
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
0-50 50-100 100-200 200-400 400-600 600-800 800-1000 1000 or more
Special note or requests: .
