Toolkit2

Speaker/Tour Request Form
To request a speaker from a United Way or Community Health Charities of Connecticut agency or to arrange an agency tour, please fill out the information below and click on the button.

Request for (check one):
Agency Speaker Agency Tour
Requested by:

Telephone/Extension:
() -
Date of Event:
/ /
Time(s):

Company:

Company Address:

City:

State:

Zip Code:

Event Address (if different):

City:

State:

Zip Code:

Company Contact (name and title):

Contact Telephone:
() -
Contact Fax:
() -
Contact Email:

Directions and/or Parking Instructions:

Anticipated Audience Size:

Anticipated Composition of Audience
(gender; age; type of workers, i.e. executive, union, administrative, etc.):

Interest/Target Area(s):

Is a specific agency being requested?:

If applicable
How much time will speaker have to present?:

Should speaker bring handouts, if available?:
Yes No
Additional Notes:

United Way of the Capital Area
30 Laurel Street
Hartford, CT 06106-1374
Phone: (860) 493-6800
Fax: (860) 493-6809