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Speaker Request Form

 

Please note that with our small staff and volunteer base that we can NOT guarantee that a representative from our Affiliate will be able to speak at your event.

1) We can only consider requests from within our 29-County Affiliate Service Area: Bladen, Brunswick, Caswell, Chatham, Columbus, Duplin, Durham, Edgecombe, Franklin, Granville, Halifax, Harnett, Johnston, Lee, Moore, Nash, New Hanover, Northampton, Onslow, Orange, Pender, Person, Pitt, Sampson, Scotland, Vance, Warren, Wake, and Wilson Counties.

2)  Requests must be received at least four weeks prior to event date.

3) Requests are filled on a first come, first serve basis and are subject to staff and volunteer availability. Requests are not considered confirmed until by Affiliate until we have contacted you about your request and you have received a confirmation from us.

4) Please note that while Breast Cancer Awareness Month (October) and Race for the Cure months (September & May) are very popular times to host events, our limited staff and volunteer core will be heavily committed during these times and may not be able to provide the same level of assistance as other times of the year.

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2. Contact Person Information and Location of Speaking Event

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Name:

 

 

   

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City/State/ZIP:

 

    

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*3. Requesting that the Komen Representative
(Select one of the available choices or enter a different value.)



*4.
Question - Required - Date of Event




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*11.
Question - Required - Audience
Please make between 1 and 8 selections from the choices below.

12.

   Please leave this field empty