Speaker Request Form
Date of the event (*required) January February March April May June July August September October November December 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 2011 2012 2013 2014
Name of the church or organization
First Name Last Name
Relationship (title) to the above organization
Email address for contact person
Contact person (if different from above) First Name Last Name
Address City
State Zip
Home phone/Cell phone/Fax
What is the start time for this event?
January February March April May June July August September October November December 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 2011 2012 2013 2014 12 1 2 3 4 5 6 7 8 9 10 11 am pm
What is the end time for this event?
How many sessions would you like Martha to speak?
Do you have a theme for the event? If so, what is it?
What is your overall goal for this event?
Name of venue
Type of event is this? Retreat Banquet Women's Event Leadership Event Other
Will this be promoted as a community wide event? Yes No
Has the event (as well as Martha’s role in the event) been approved and confirmed with the staff of your church or organization? Yes No
How many are you expecting to attend? <50 50-100 100-150 200-250 >250
Age demographics of those expected to attend: 18-24 25-30 30-40 40-50 50-60 60+ All Ages
Estimated percentages of believers, seekers, etc.
Will additional keynote speakers be involved? If yes, please list.
How did you hear about Martha?
Has your church or organization completed Martha’s Bible study, Attending the Bride of Christ: Preparing for His Return? Yes No
Please include any questions regarding this profile or Martha’s speaking calendar in the box below.
*Martha’s messages may not be audio or video taped or broadcast without written permission prior to any event.
