DR. ANTHONY CAMPOLO INVITATION INFORMATION FORM

Eastern University

1300 Eagle Road  St. Davids, PA 19087

610-341-5962 (Phone)  610-341-4372 (Fax)  

Important Note: Please fill out form completely. This will help us in determining if this event is one that Dr. Campolo can accept. If accepted, it will also provide us the necessary information about you and your engagement that helps us plan best. This is two pages in length. When you have completed this form, please save it as a Word Document and email it to, Dr. Campolo’s assistant, at , as an attachment. Due to Dr. Campolo’s heavy travel schedule, please allow 4 weeks for your request to be processed through our speaking review committee. Thank you.

Sponsoring Organization:
Organization’s
Complete Address:
Please Include Country if Outside of USA
Organization’s Website:
Your Primary Contact / Your Alternate Contact
Contact Name: / Contact Name:
Contact Title: / Contact Title:
Contact E-mail: / Contact E-mail:
Contact Work Phone: / Contact Work Phone:
Contact Extension: / Contact Extension:
Contact Mobile: / Contact Mobile:
Contact FAX: / Contact FAX:
Contact Home Phone: / Contact Home Phone:

Engagement Information

Organization’s Profile:
Program Description:
Proposed Date(s): / Start Time of Meeting
Proposed Alternate Date(s): / Finish Time of Meeting
Day(s) of the Week / Attendance:
Type of Engagement: / Public Meeting
Choose Yes/No:
Event Location: / Nearest Airport:
Event City/State / Max. time to airport from event:
Time Zone Location: / Number of miles to airport from event:
Audience Profile: / Registration Fee
Choose Yes/No:
Proposed Honorarium: / Submission Date:

PLEASE CONTINUE ALL THE WAY TO THE SIGNATURE LINE ON THE NEXT PAGE

DR. ANTHONY CAMPOLO INVITATION INFORMATION FORM PAGE 2

610-341-5962 (Phone)  610-341-4372 (Fax)  

Please provide a full description of Dr. Campolo’s role at this engagement:

Suggested Date of Meeting / Specific Time of all Meetings Where Dr. Campolo Speaks / Length of
Meeting / Length of Dr. Campolo’s Message / What is the Specific Topic(s) you want Dr. Campolo to Address? / Type of Meeting / Number
Expected

Please provide anything else you would like Dr. Campolo to know about your engagement.

Do you want brochures that represent Dr. Campolo’s ministries? YES ______NO______

Dr. Campolo’s books help tell his story and allow participants to learn more and continue the experience. Will you allow Dr. Campolo’s books to be available at this engagement? YES______NO______

An electronic signature is valid on this form.

Form complete by:______Title: ______

Signature: ______Date:______