Speaking Request Form Contact InformationChurch or Organization Name*Physical Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please note: We prioritize speaking engagements in North America.Contact Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Phone*Email* Is your church/organization a current supporter of the Chalmers Center?* Yes No Do you have plans to call the audience to respond practically to the message presented at your event?* Yes No I'm not sure what you mean by this. What is your church/organization's denominational affiliation?*Event DetailsFirst Preferred Date* MM slash DD slash YYYY Second Preferred Date* MM slash DD slash YYYY Event Location*Describe the vision, purpose, and/or theme of the event.*What is the specific role and message content you envision for Brian for this event?*Are you open to an alternate speaker from the Chalmers Center if Brian is not available?* Yes No Who is the audience for this event?*What is the expected attendance at this event?*Will the event site have appropriate A/V set-up and personnel?* Yes No Please note: Because we use visual diagrams to illustrate key concepts, an easily-visible LCD video projection system to display presentation slides and voice amplification that enables everyone to hear well are necessary. Presentations may include videos, so the A/V system needs to be adequate for playing video files (MP4, MOV, or streaming from Vimeo). We ask that hosts have a qualified A/V contact perform a pre-event test display of the slides and sound check. Except in extremely rare cases, the presentation will be played from the Chalmers Center's MacBook or MacBook Air computer, controlled from a USB connected pointer. If this is not possible, please let us know at least 2 months in advance of the event.Please provide as detailed an event schedule as possible. You may upload a schedule document if you prefer.*Please include: Scheduled times Brian would speak; Meetings you would like Brian to attend; Meals Brian is invited to; How long his message(s) should be; If there will be other speakers at the event; and any other relevant details.Schedule Document(s) Drop files here or Select files Accepted file types: pdf, doc, txt, Max. file size: 512 MB. Travel / TransportationClosest airport to event location:*Approximate travel time to event location from airport:*Is your church/organization able to reimburse the Chalmers Center for Brian's travel expenses: airfare, hotel, meals, rental car (if needed)?* Yes No Please note: When Brian travels, we do our best to purchase the most reasonably priced airfare, etc. Because Brian is 6' 10" tall, he needs to have economy plus or first/business class seating on flights lasting more than 2 hours. Reimbursable travel expenses (within the U.S. and Canada) will not exceed $1,250.00 unless agreed upon in advance.Other InformationWhat opportunities would be provided at this event for Brian to speak specifically about the work of the Chalmers Center and its financial needs?*Would the Chalmers Center be permitted to set up a display and offer resources to event attendees?* Yes No The host agrees to provide the Chalmers Center with an accurate count of event attendees and to respond to evaluation form(s) sent by the Chalmers Center after the event.* I/we agree. Brian's message(s) may not be recorded/redistributed without direct written consent of the Chalmers Center.* I/we agree. Please provide any other information about the event, along with any questions you may have. Δ
