Speaker Request Form

Please complete this form to book Mary Dittman as a speaker at your event.

Click the button below to start.


Question 1 of 10

What is the name of your organization and event?

Question 2 of 10

Who is the contact person?  Please give name, email address, and phone number.

Question 3 of 10

What is the date and time of the requested event?

Question 4 of 10

If Mary is not available on that date, would you like to request an alternate date?  If so, please state the alternate date(s).

Question 5 of 10

How many people will attend the event?

Question 6 of 10

Are you requesting an in-person appearance, video appearance, or both?






Both in-person and video

Question 7 of 10

If in-person, where will the event be held?  If video, which platform will you be using?

Question 8 of 10

How long to do you want Mary's talk to be?

Question 9 of 10

What topic(s) is your group interested in hearing?  What do your members most need or want to hear?

Question 10 of 10

What other information do you need us to know about your group or this event?

Confirm and Submit