*Date Submitted                   

*Name of your organization      

 Purpose or mission of your organization

*Your name Title

*Phone #      Fax #

*E-mail               
*E-mail (Repeat)  

*Topic of Program

*Date of event    *Time of event  

*Time allocated to speaker (minutes)  

*Location

Other events scheduled at that event

*Estimated attendees

Age Group  

*Is a Meal Served?    No      Yes    Time of meal

Items marked with * are required.

Submit request via this web-form, or  FAX: 1-408-732-2902  or

call Guy Thompson - Speaker bureau coordinator:  1-408-732-4400  

Upon receiving your request our coordinator will contact you by phone.

NOTE:  If your request is accepted the designated speaker will contact you
regarding your meeting facility resources like projectors, lectern, display boards etc.

How did you learn about our organization? 

Thank you for your interest in SCORE.

I further understand that any counselor/speaker has agreed not to (1) recommend goods or services from sources in which he/she has an interest and (2) accept fees or commissions developing form this counseling/speaking relationship.  In consideration of the counselor(s)/speakers furnishing management or technical assistance, I waive all claims against SBA personnel, SCORE and its host organizations, and other SBA Resource Counselors/speakers arising from this assistance.