REQUEST FOR SPEAKING ENGAGEMENT
WITH TIMOTHY DIMOFF

Name of Organization: Contact Person: Address: City, State, Zip: Phone: Fax: E-mail: Title of Event: Name & Cell Phone Number of the on-site contact person: Name: Cell Phone: Proposed dated and times requested: 1st choice:  Date:  Time: 2nd choice:  Date:  Time: 3rd choice:  Date:  Time: Location of Event: Address: City, State, Zip: Topic Desired: Length of Time: Number of People Expected: Is there an overhead/screen available?: Yes No Is there a flip chart and/or marker board available?: Yes No Is there a powerpoint projector available?: Yes No Is there a laptop available?: Yes No Additional comments/requests:

PRIVACY STATEMENT