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