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campaign toolkit : day of caring: agency speaker tour programs
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.  Please note: If you have trouble viewing the form below, please download a .pdf version here, print it out and fax it to Mary Wolf (860)493-6832

Date of Event
Event Start Time:
Event End Time:
Total Time for Speaker to Present:
Company Name:
Department/Business Unit:
Request for (check one):
Agency Speaker Agency Tour Agency Fair
Requested by:
Telephone/Extension
( ) -
Company Address:
City
State
Zip Code:
Event Address (if different):
City:
State:
Zip Code:
Company Contact (name and title):
Contact Telephone:
( ) -
Contact Cell:
( ) -
Contact Fax:
( ) -
Contact Email:
Website
Directions and/or Parking Instructions:
Anticipated Audience Size:
Anticipated Composition of Audience (gender; age; type of workers, i.e. executive, union, administrative, etc.):
Specific Interest/Target Area(s)?
Is a specific agency being requested?:
Additional Notes: