Guest Speaker
Information

Point of Contact Name: *

First Name

Last Name

Point of Contact Phone: *

(###)

###

####

Point of Contact Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guest Speaker Name: *

First Name

Last Name

Guest Speaker Phone (Work): *

(###)

###

####

Guest Speaker Phone (Cell): *

(###)

###

####

Guest Speaker Mailing Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guest Speaker Personal Address: *

Personal Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday *

MM

DD

YYYY

Emergency Contact Name: *

First Name

Last Name

Emergency Contact Phone: *

(###)

###

####

Spouse's Name

First Name

Last Name

Wedding Anniversary

MM

DD

YYYY

Church/Ministry Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Church/Ministry Phone: *

(###)

###

####

Make Honorarium Payable To: *

First Name

Last Name

Will you be traveling with your personal microphone?

Yes

No

What type of microphone do you prefer?

Headset - Double Ear

Headset - Single Ear

Handheld

No Preference

Media Contact

First Name

Last Name

Media Contact Phone:

(###)

###

####

While Speaking on Platform:

Acrylic Lecturn & Small Table

Bistro Table & Swivel Stool

Please let us know if you would like a different setup and we would be happy to accomodate.

How will you be traveling to Longview?

Car

Air

Arrival Date

MM

DD

YYYY

Time

Hour

Minute

Second

AM PM

Departure Date

MM

DD

YYYY

Time

Hour

Minute

Second

AM PM

Do you require a rental car while in Longview?

Transportation is available for you by a staff member of Grace Creek..

Yes

No