SPEAKER REQUEST FORM

This form is for requests from Ohio State alumni clubs and societies only. Unfortunately, we cannot assist with requests from outside groups.

Group Name:
Event Coordinator's Name:
Address:
City:
State:
Zip:
Day Phone:
E-Mail:

1. Our group's choices for a speaker are (in order of preference):
a.
b.
c.
d.

2. Our group's choices for a meeting date are (in order of preference):
a.
b.
c.
d.

3. Name of last university speaker:

4. Date of last group meeting:

5. Our group:
WILL use Outreach and Engagement printing and mailing services.
WILL NOT use Outreach and Engagement printing and mailing services.

6. In an effort to meet your group's request for a high profile speaker, would you consider having a regional meeting?
Yes
No
Please indicate nearby counties and/or cities: