Speaker request form

Consent for storing submitted data *

Yes, I give permission to store and process my data

Your name *

Contact number *

Email address *

Organisation name *

Organisation website *

Type of organisation *

Trade Association

Consumer Body

Firm

Bank

Conference Organiser

Press/Media

Government

Think Tank

Other

If other - Please describe the type of organisation

Event title *

Do you have a speaker you have in mind for your event? *

Yes

No

If so, have you already approached them about this event?

Yes

No

And, who did you have in mind? *

What is the format of the session? *

Speaker

Keynote

Panellist

Roundtable

Other

If session type if other, please describe the session *

Title of speech/session *

Date of the event *

Time of event *

Location *

Length of speech/session *

What is the purpose of this event? *

Audience (sector and level) *

Expected numbers

Is your event *

Invite only

Paid for by delegates

Other

Please provide a link to your event webpage (if available)

Is the event: *

Public - on the record

Chatham House Rule

Private - off the record

Will journalists be present? *

Yes

No

Will there be Q&A? *

Yes

No

Will anything be promoted or published following this event? *

Do you have regular contact with anyone at the PSR? *

Yes

No

If yes, please enter a full name *

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Speaker request form