Speakers Bureau

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Speaker Request Form

Thank you for inviting our Rockford Chamber of Commerce speaker to be part of your program. To help us continue improving our Speakers Bureau, please give us your evaluation of our service. Your comments are valuable to both the speaker and the Rockford Chamber. We'd appreciate a response from you within 10 days of our speaker's presentation to your group.

Name
Company
Address
City	State	Zip
Telephone
Email
Name of Speaker You are Requesting
Topic of Interest
Additional Information or Special Requests:
Level of Presentation:		Basic
		Intermediate
		Advanced
Date of Presentation (mm/dd/yyy)	Time
Are you flexible with the date and/or time?	YES	NO
Length of Presentation	Approximate Attendance
Audience Description:
Are you a Rockford Chamber Member?	YES	NO