Training or Speaker Request Form – KYS CONSULTING GROUP

Name of agency/organization: *

Website URL:

Briefly describe your agency (public/private, profit/nonprofit, purpose, population served, etc.) :

Primary contact person name: *

First

Last

Telephone number:

Email *

Email

Confirm Email

Specific date requested? *

Requested date and time of training: *

Date

Time

Provide any additional information and/or possible dates: *

Allotted amount of time for speaker:

Describe the audience; please select all that apply: *

Please provide additional detail about the audience(s) you selected *

Approximate expected number of attendees:

Requested topic for training/presentation: *

Specify your topic for training/presentation if you selected other: *

Audience’s current level of knowledge of the subject: (check all that apply) *

Describe here: *

Audience’s current level of knowledge of the subject: *

Location:

Provide address if you selected in person for location. *

Address Line 1

Address Line 2

City

State

Zip Code

Within 60 miles of Raleigh? *

Will you be covering mileage, lodging, and/or meal costs? *

Please provide additional detail about coverage for mileage, lodging, or meal costs: *

What equipment do you have available for the presentation, select all that apply: *

If you selected other above please list the equipment you will have available that is not listed: *

What is your budget for the presentation/event? *

Please provide a dollar amount.

Any additional information you would like us to know? *

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.