Speaker/Technical Assistance Request Form

Fill out the following information to submit your request for a speaker or technical assistance. Please understand that we can only serve areas that are within our capacity to do so. If you have any questions please call (859) 278-8109. Please submit this request through email by clicking on the “Submit Your Request” button at the bottom of this page. You will be contacted soon after your submission to further process your request.

Please fill in all fields!!

Contact Information

Name:

Organization:

Street Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Email Address:

Event Information

Date of Event:

Time of Event: AM PM

Event Location:

Phone at Location:

Address of Event:

City:

State:

Zip Code:

Nature of Request:

Audience:

6th – 12th Grade Students: Please indicate grade level(s)

College Undergraduate Students

College Graduate Students

6th – 12th Grade Teachers

College Professors

Business/Professional: Please Indicate sector(s)