Speaker Request Form

Instructions: This form is for requesting a speaker on Islam & Muslims from the Tours & Talks program at the Islamic Center of Greater Cincinnati in West Chester, Ohio. Please complete this form and submit. You may call 513-755-3280 to confirm its receipt. The talk at your location can be for 1-1 ½ hours. The speaker may utilize PowerPoint or other audio visual materials. Some basic informational literature can be provided for your group. A $75-200 donation to the Islamic Center is suggested for the program and literature.

Organization or Individual

Address

Street Address

Address Line 2

City

State

Zip Code

Initial Contact Person

Initial Contact Date

Cell Phone

Work Phone

Fax

What dates and times are convenient?

What type of organization is represented?

To learn about Islam To learn about other cultures Other

How many participants are expected?

Do the participants have any previous knowledge of Islam?

Yes No

What are your expectations as to the length of visit?

Any additional comments that would help address the group’s needs:

Speaker Request Form

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