KSC Speakers Bureau - Online Speaker Request Form

Note: Fields with the red star are required fields

Request for NASA Guest Speaker

INSTRUCTIONS
Speakers are provided, when available, at no charge. Travel costs, for speaking engagements requiring out-of-town travel, however, are usually borne by the requesting organization. You will hear from us as soon as a determination is made as to whether a speaker can be scheduled. NOTE: This report is authorized by law (42 U.S.C. 2473). While you are not required to respond, your cooperation is needed to enable us to provide the service you requested.

To	(Name & address of NASA installation)
	Layla Higgins
	Mailcode: XA-F
	Kennedy Space Center, FL 32899
	Phone: 321.867.5048
	Email: Layla.M.Higgins@nasa.gov

From	(Name and Address of sponsoring organization)
Name	*
Address	*
City	*	Zip
State
Country

EVENT Name or Title

Date of Event
(MM/DD/YYYY)

Time of Event
Begin * End *

Location

(Name & address of hall, auditorium, etc., room, tel. no., if any)
*

Social Hour Included

Social Time Allowed (if YES)

SPEECH Topic Desired

Question/Answer Period

Q/A Time Allowed (if YES)

EQUIPMENT (As available) Description
Screen Lectern Light Pointer Qualified Projectionist	Slide Projector (2 x 2 inches) Public Address System Lavaliere or Lapel Microphone	Slide Projector (3 1/2 x 4 inches) Room can be Darkened for Films, Etc. Motion Picture Projector (16mm with optical sound)

AUDIENCE Anticipated Size	*	Composition (Teachers, businessmen, general public, family, etc.) *
EXCLUSIONS Is, or will any person, for reason of race, color, sex, religion, or national origin, be excluded from or segregated within membership in sponsoring organization, attendance at event or any of the facilities housing this event? * Yes No \| Event Open to Press * Yes No

Speech to be Broadcast * Yes No | Photo/Biographical Sketch Needed * Yes No

Speech to be Taped, Filmed, or Otherwise Recorded (if YES, briefly explain below) *

If Yes, explain

REMARKS

Furnish any other significant information which may be helpful in the selection of an appropriate speaker, such as: Whether NASA speaker will deliver keynote address, participate in panel discussion, etc.; if there is a special purpose or objective or any unique feature involved. Also, please indicate whether or not there is a date deadline for getting a speaker.

Contact Name	*	Tel.	*
Address	*	Email

Please carefully review your information before you submit