Speaking Engagement Request

Disclaimer: This form does not guarantee or confirm the representative's attendance to any engagement. The representative and his staff will review each submission and follow up with a contact person to discuss any further detail. Should you have any questions please feel free to contact us at (850)717-5008 or via email on the Contact Page. Thanks!
Click Here To Download Speaking Engagement Form (MS Word Format)

All fields below are required.

Event Name

Event Date

Event Time

Exact Location to Meet

Contact Name for Event

Contact Number

Contact Email

Approximately how many guests do you expect to attend?

Please list the name of the individuals that should be recognized publicly at this event.

Please list the President of the Organization as well as any other individuals that played an active role in this event.

Please provide some background information and mission statement for this group.

What issues does the group want Rep. Alexander to speak on?

How long are the remarks to last?

Will a podium be present for Rep. Alexander to use?

Attachment - Not required (PDF, DOC, JPG, PNG file types only. DOCX files will not submit! - 2MB filesize max)