ALLAN HOUSTON PUBLIC SPEAKING REQUEST FORM

Name of Person/Organization Making the Request :

Contact Person Information
Name :	Telephone :	E-mail :

Nature of the Request :    Choose one Business Charitable Media Other

If business, what is the goal and who will be targeted?.

If charitable, what is the cause and who will benefit?.

If media, what is the format and where will it appear?.

Other.

If Requesting Attendance of an Event, Also Provide:

Specific Date or Possible Dates :

Month January February March April May June July August September October November December

Year             2008 2009 2010 2011

Location :
Venue & Address	City	State      Choose one  AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Intended Transportation :

Event Time :

Desired Arrival Time :

Length of Appearance Requested :

Specific Level of Involvement Requested (e.g. hosting, speaking, interviews, autographs, photo ops, etc.)

* Proposed Fee or Honorarium (with specific terms of payment noted)

Any Other Pertinent Info or Details