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Speaker Request Form
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Speaker Name (First and Last Name)
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Company
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Phone Number
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Email Address
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Website
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Professional Introductory Bio
Books/CD’s/Articles Published
1st Reference - Where have you spoken before? Name of Audience / Contact Person / Title / Company / Phone No
2nd Reference - Where have you spoken before? Name of Audience / Contact Person / Title / Company / Phone No
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Type of Presentation Method - check all that apply
Virtual
In Person
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Title: Clearly describe your session in 10 words or less
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Description: Describe your presentation in 100 words or less
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What business challenge(s) does your program address?
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Key Learning Objectives
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Which ATD capabilities most align with your topic? Follow link to learn more: https://www.td.org/capability-model
Building Personal Capability - Communication
Building Personal Capability - Emotional Intelligence & Decision Making
Building Personal Capability - Collaboration & Leadership
Building Personal Capability - Project Management
Building Personal Capability - Compliance & Ethical Behavior
Building Personal Capability - Lifelong Learning
Developing Professional Capability - Learning Sciences
Developing Professional Capability - Instructional Design
Developing Professional Capability - Training Delivery & Faciliation
Developing Professional Capability - Technology Application
Developing Professional Capability - Knowledge Management
Developing Professional Capability - Career & Leadership Development
Developing Professional Capability - Coaching
Developing Professional Capability - Evaluation Impact
Impacting Professional Capability - Business Insight
Impacting Professional Capability - Consulting & Business Partnering
Impacting Professional Capability - Organizational Development & Culture
Impacting Professional Capability - Talent Strategy & Management
Impacting Professional Capability - Performance Improvement
Impacting Professional Capability - Change Management
Impacting Professional Capability - Data & Analytics
Impacting Professional Capability - Future Readiness
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How will you engage the audience in learning?
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What best practices, case studies, etc will you share?
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When are you available to present?
EVENT RUNNING TIME: 6:00 TO 7:15 PM – Speaker Presentation: 6:00 to 7:00 PM – Q&A / Announcements: 7:00 to 7:15 PM – Event Closure: 7:15 PM
First Quarter (January - March)
Second Quarter (April - June)
Third Quarter (July - September)
Fourth Quarter (October - December)
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Provide speaker’s LinkedIn profile
Will the speaker share the presentation and/or materials for the event?
Yes
No
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Does the speaker agree to having the session recorded?
The recording will be available only to ATD chapter members and guest attendees.
Yes
No
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