Speaker Event-Audience Names

 

Thank you for considering Susan G. Komen Dallas County to speak at your upcoming event! 

Please complete the speaker request form if it has not been completed prior to completing the audience form.  Click here for the Speaker Request Form.   

 

Event Details

*
Question - Required - Event Date




*  


  Event Requestor's Contact Information Only (Not Audience Names)

*

Name:

 

 

   

*

*

 


*  


 

Please provide a list of minimum 20 audience members.  This information is needed to secure a speaker.  Your commitment to the audience size is needed in order to be respectful of the speaker's time for the event.  Please provide the audience's first and last name in the spaces provided below.

*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


*  


   Please leave this field empty