SPEAKER(S)/PRESENTATION REQUEST FORM
Updated May 2, 2016
CAIR-WA has established a speaker request process in order to efficiently evaluate and accommodate speaking and presentation requests.  We recommend at minimum a three-week notice for a speaking engagement or presentation.  This form must be fully completed by the requesting party. Incomplete forms may not be processed.
Please send fully completed Speaker Request Forms by e-mail:  info@cairseattle.org and in the subject line, please clearly mention “Speaker Request.” Please allow 5 business days for us to respond to this request. 
Speakers referred by CAIR-WA in response to speaker requests are typically not CAIR personnel and should not be advertised or described at events as associated with CAIR.  Speakers referred by CAIR-WA are local residents actively engaged in their communities and have some background that enables them to speak knowledgeably on a given topic. They are referred to the requesting party based on the specific topic, audience, location, and other event details provided by the requesting party in this form.

CAIR's mission is to enhance understanding of Islam, encourage dialogue, protect civil liberties, empower American Muslims, and build coalitions that promote justice and mutual understanding.

1. EVENT SPONSOR INFORMATION 	
	
Today’s date: 	
Main sponsor: 	
Primary contact person: 	
Office phone: 	
Main phone number: 	Alternate phone: 	
Email:	
Main office address: 	
	
Secondary contact person:	
Phone:	
Email:	
Secondary sponsor(s) (if applicable):	
2. SPEECH INFORMATION 	
Date of event:	
Event starts at: 	Ends at: 	
Speaker portion starts at: 	Duration of speaker portion:	
Will there be a Q and A Session?
a Yes     a No	If yes, indicate duration of Q&A:	
Location of event (name of site):
	Specific
room:	
Street address:	
	
Suggested title/topic:	
Event theme, if applicable:	
What are the top 10 questions audience members would like to have answered/clarified during this presentation? 	
Do you need a Muslim speaker or any speaker, regardless of faith, who is knowledgeable about Islam/Muslims or the topic? 	
Describe any qualities/attributes of the ideal speaker for this event:	
What are the key ‘take away messages’ you would you like the audience to take from this presentation and what actions if any would you like them to be inspired to take after hearing the speaker(s)? 	
Speech/presentation format:
a Single topic speaker
a Panel of speakers (please list other panelists & their affiliations in the right hand column)
a Film viewing/discussion
a Other—please specify:	
Please list full names and affiliations of all other possible and confirmed panelists and speakers at the event:  	
Set up of room:
a Theater style – specify size: 
a Classroom style – specify size: 
a Other – please specify style size: 	
This speech/presentation is part of a:
a Multi-day conference—please specify:
a One-day seminar— please specify:
a Class presentation— please specify:
a Other—please specify:	
Have you contacted other organizations to request a speaker for this event? If so, please list all other organizations you’ve also contacted to request a speaker. 

Important:  Please explain the sponsor’s mission. Also explain the intent of this speech/presentation, and why you have chosen to contact CAIR-WA to provide speakers/presenters. (Please explain this in detail. Supporting documentation is welcome for further explanation.)	

3. HONORARIUM INFORMATION.  We have no set fees. Groups have chosen to provide honoraria that range from $250 to $15,000 dollars depending on the event and the budget for the event.
	
Amount offered:	
Date by which honorarium will be sent (minimum 5 business days prior to day of event):	

4. AUDIENCE INFORMATION
(We collect this information so that we may find speakers that best fit your audience.)	
Language of Delivery: 	
Expected number of attendees:
	Previous Attendance numbers (if known/applicable):
	
Is the majority of the audience members:   a Female     a Male     a About 50/50
a  Muslim     a Christian     a Jewish     a Other (please specify):

Political views/affiliations of the audience members:
Socialist Party: _____%     Democratic Party: ______%     Republican Party:  ______%      Tea Party: ______ %

What is the educational level of the majority of the audience?
a High school  a Bachelor’s degree   a Graduate degree  aSpecialized area: _________________________	
Any further description of the audience?	
5. Other Information	
What audio and video amenities are provided? 
a Projector  a Screen  a Laptop connected to projector  a Clicker for PowerPoint slides a Sound system for laptop/projection    a Microphones & sound system for speaking  aOther – please specify: 	
Will this speech be recorded? (Check all that apply)   a Audio recorded     a Video recorded     a Transcribed
If you checked any of the above, please note that your organization will be required to deliver the master recordings of the talks within two weeks for our archives and production purposes.  Any use or duplication of the talk in any form or for any purpose must be fully reviewed and approved by CAIR-WA.	
Will the press cover this event?         a Yes     a No	
If yes, please describe the nature of the media coverage:	
What parking is available at the site? Please also specify exact parking location and details. 
a Street parking     a Free parking     a Metered parking     a Other (please specify):	
Is parking free for speakers? a Yes  a No  
Please also specify exact parking location and details. Attach map if needed.	
Additional comments:	

Please send fully completed Speaker Request Forms by e-mail:  info@cairseattle.org and in the subject line, please clearly mention “Speaker Request.”  Incomplete forms may not be processed.
Please allow 5 business days for us to respond to this request. Please feel free to contact our office at info@cairseattle.org or via phone at 206.367.4081 at any time with any questions.