Fax Request


For United Way Speakers
   
Your United Way Representative ___________________________________
Company Requesting Speaker _______________________________
Company Contact Name _____________________________
Address ________________________________
Phone ______________   Fax _________________
E-mail Address __________________________
Location of Event __________________________
________________________________________
Requested Topic (first choice) _____________________________
(second choice) _________________   (third choice) _________________
Speaker (first choice) ___________________________
(second choice) _________________   (third choice) __________________
Date _________ Time_________ a.m./p.m   Length of Presentation Desired_______
Size of Audience _________ Type of Audience _______________
Dress of Audience (professional, casual, etc.) ____________________
Video Presented? _____ Yes  &nsp;______ No
Other Requests
_________________________________________

It is best if agency speakers could be scheduled two weeks in advance.
After completing the above form, fax it to 937-383-0956
Or email to unitedwaycc@in-touch.net

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