top of page

Speaker Request Form


Date of Contact _________________________________________________

Contact Person _________________________________________________

Organization ___________________________________________________

Contact Phone _________________________________________________

Contact e-mail _________________________________________________

Topic ___________________________________________________________

Date confirmation is needed ___________________________________

Length of presentation _________________________________________

Date ____________________________________________________________

Day ____________________________________________________________

Time ___________________________________________________________

City ____________________________________________________________

Number of people _____________________________________________


  • It will be the speaker's responsibility to contact the organization to finalize the details.

  • Have the organization make checks out to University of Missouri Extension.

  • If the organizization requests  a form that they can use for tax purposes, contact the extension.

  • If the facility where the talk is held is outside St Charles County, an additional milage fee is assessed. This fee should be included in the amount of the check from the organization. After turning the check into the extension, the speaker can then request to be reimbursed the mileage amount from the extension.

  • The amount will be calculated based on the mileage from St. Charles County Extension Center to the address of the speaking engagement using Google maps at a rate of $.20 per mile.






bottom of page