Speaker Request Form

Please complete the form below to request a speech by Abdul Karim Yahya

Event Sponsor Information
Today's date: / MM / DD YYYY
Main sponsor:
Secondary sponsor(s):
Primary contact:
Telephone number: - ### - ### ####
Email
Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Speech Information
Date of speech: / MM / DD YYYY
Event theme:
Session starts at: : HH MM AM/PM
Session ends at: : HH MM AM/PM
Q & A
Yes No
Duration (if the speech has multiple sessions, please provide information regarding each session):
Event street address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Location of event: Specific room
Suggested title/topic:
Speech format:
Single topical speaker Panel of speakers (please attach list of other panelists & their biographies) Teacher of a course (please attach list of other teachers, their biographies & courses) Other - please specify
This speech is part of a
Multi-day conference - specify: One-day seminar - specify: Fundraising lunch/dinner - specify: Other - please specify:
What is the sponsor's mission and the intent of this speech, and why have you chosen Abdul Karim Yahya? (Supporting documentation is welcome for further explanation)
Honorarium Information
Please check one of the honorarium payment options:
We will send honorarium in advance of speech We will provide honorarium on the date of the event
Audience Information

Pleaes provide information regarding the audience.
Language of Delivery
Arabic English
Expected Attendance:
Previous Attendance (if applicable):
Estimate appropriate percentages:
Gender (majority):
Male Female Equal male/female
Religion:
Muslim Christian Jewish Other
Education:
High school Bachelor's degree Graduate degree Professional
Please describe the audience (supporting documentation is welcome for further explanation).
5: Other information
Will this speech be recorded? (check all that apply)
If you check any of the below, please note that your organization will be required to deliver the master recordings of the talks within one week for our archives and production purposes. Any use or duplication of the talk in any form for any purpose must be fully reviewed and approved by Abdul Karim Yahya.
Audio recorded Video recorded Transcribed
Will the media cover this event?
Yes No
If yes, please describe the nature of media coverage.

Speaker Request Form

Speaker Request Form

Event Sponsor Information

Speech Information

Honorarium Information

Audience Information