REQUEST FOR SPEAKING ENGAGEMENT
WITH TIMOTHY DIMOFF

Name of Organization:	__________________________________________________
Contact Person:	__________________________________________________
	Address:___________________________________________
	City:_______________________ State:______ Zip:_________
	Phone: (_____)_____________ Fax: (_____)______________
Title of Event:	__________________________________________________
Proposed dates and times requested:
	1st Choice: Date:___________________ time:______________
	2nd Choice: Date:___________________ time:______________
	3rd Choice: Date:___________________ time:______________
Location of Event:	__________________________________________________
Address:	__________________________________________________
	City:_______________________ State:______ Zip:_________
Topic Desired:	__________________________________________________
Length of Time:	_________________
Number of People Expected:	_________________
Is there an overhead/screen available? ______ Yes ______ No
Additional comments or requests:

*PLEASE FAX OR MAIL A MAP, ALONG WITH THIS FORM, TO:
Mr. Tim Dimoff • Premier Suites • 500 Grant Street • Akron, Ohio 44311
Phone: (330) 255-1101     Fax: (330) 255-1135