Speaking Request Form Church / Organization InformationName of your church or organization*Denomination (if applicable)Church / Organization Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Church / Organization Phone*Church / Organization FaxChurch / Organization WebsiteDoctrinal statement of your church/organization (if you have never before hosted Dr. Scott):Venue*Venue Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Venue Phone*Pastor or Primary Contact for this Event* First Last Pastor or Primary Contact Home Phone*Pastor or Primary Contact Cell Phone*Pastor or Primary Contact Email* Secondary Contact First Last Secondary Contact Home PhoneSecondary Contact Home CellPastor or Primary Contact Email First Choice for Event Date* Date Format: MM slash DD slash YYYY Second Choice for Event Date Date Format: MM slash DD slash YYYY Nature of the event (i.e. conference, men's retreat, pastors' conference, Sunday worship service, etc.).*Number and length of times Dr. Scott is to speak, possible topic(s) and possible schedule (Please refer to the speaking topics page, but note that these details may be discussed and finalized in future correspondence).*Will PowerPoint capability and equipment be present?*(Dr. Scott prefers to use PowerPoint and requests that he be able to toggle the slides himself as well as have a laptop or screen in front of him.)YesNoWill there be a large whiteboard available?*YesNoWill there be any other speakers at this event?*YesNoPlease list all other speakers.Will there be music or other components included in the event?*YesNoPlease describe.What is the approximate anticipated attendance of this event?*Who is the target audience?*Into which airport will Dr. Scott fly, and how far is the airport from the event?*NameThis field is for validation purposes and should be left unchanged.