Speaker Request Form

Genesis is happy to provide a speaker for your event.

A minimum of two weeks notice is required. Requests received with less than two weeks notice cannot be guaranteed.

Requesting Organization Information

* denotes required field

*Last Name:  
*First Name:  
*Organization Name:  
Organization Type:
*Day Phone:  
Extension:  (if used)
Evening Phone:  
Email Address:  
Confirm Email Address (retype):  

Event Details

*Date:  (mm/dd/yyyy)  
*Time:  (e.g., 7 p.m.)
*Presentation Length:  (length of speaker's talk in minutes)  
Event Length:  (length of the event in minutes)  
*Event Topic:
Alternate Event Topic:
Type of Event:  (e.g., luncheon, dinner, reception)
*Type of Audience:
(e.g., student, seniors, church group)
*Size of Audience:
*Other Audience Info:
(e.g., gender, age range, education, etc.)

Available A/V Equipment

To assist your presenter with planning, please indicate the resources available at the facility where your event will take place. Select all that apply.

Comments / Additional Info:

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1227 E. Rusholme Street Davenport, IA 52803 563-421-1000