NAP Speaker Request Form

Speaker Request Form

30 Day Notice Requested
Name of Organization*
Organization Website*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Date of Event*

MonthDayYear
Time of Event*

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option
Dates are flexibleTimes are flexible
Name of Event*
Location of Event - If different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Audience Demographic*

Youth/AdolescentSpanish SpeakingWomenMen Who Have Sex With Men (MSM)Corporate/CommunityUnsettled/Unhoused (Housing Assistance)Living With HIV/AIDSPrEPOther
Audience Size Expected*
Is Power Point Presentation Supported*

YESNO
Preferred Language of Presentation*

EnglishSpanish
Service Fee*

A fee for service of $35 may be requested for an educational presentation. This fee may be waived for ongoing community partners or other nonprofit groups. Please click here to acknowledge this fee.
Other Information/ Requests
Should be Empty: