Request A Speaker Form



To request a speaker, please complete the form below. Because of the high number of invitations we receive to speak about non profit fundraising, we are not able to fulfill every request for a speaker.

Please tell us about your organization and your event, and we will reply to you within one week.

Fields with an asterisk (*) must be completed.

Requester Information

First Name:*

Last Name:*

E-mail Address:*

Phone Number:*

Organization Information

Name of Organization:*

Address 1:*

Address 2:



Zip/Postal Code:*


Event Information

Type of event for which you would like a speaker:*

If other, please explain:

Event Location City:*

Event Location State/Province:*

Has a date been set yet?*

Yes No

If yes, what is the date?

If no, what is the general time frame?

Who will attend this event?
Please check all that apply:

Executive Director(s)
Development Director(s)
Board Member(s)

If other, please explain:

How many people are you expecting to attend this session?*

Do you have any funds allocated for travel expenses?*

Yes No

Is there any other information you would like us to know?

How did you hear about Extended Hearts?*


(Note: Extended Hearts Community Partners & Extended Hearts, LLC  does not sell, rent, exchange, or give away any contact information.)
This information is strictly confidential


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