JOHN WALLACE


Speaker Request Form


John Wallace

Please Fill out the following "Do-it-yourself" Booking Form for JOHN WALLACE to speak before your group about "Liberty in America: Is Time Running Out?" (approx 1 hour Power Point Presentation) or some other subject and/or to be a Guest on your Radio or TV show.

When you have completed the form, click the Submit button. After we receive your request, we will contact you via email or telephone. If you have any additional questions/comments, please include them at the bottom of this form.

If you prefer to schedule by phone, or if the request is for a Radio or TV interview, please call: 518-392-7062 or email John at: john@teapartyrep.com.


Please fill out the form completely. Thanks.
Name of Organization or Group:
Location of Appearance:
How many people are expected:
Date desired:
Starting Time - Hour and Minute: AM PM
Desired Ending Time - Hour and Minute: AM PM
Contact person in Your organization responsible for setting this up: Name of Contact:

Email of Contact:

Contact Tel #

Contact Fax#
Any Comments, Issues, Questions or Special Instructions you may have:





This document maintained by the Gray Rider.
Material Copyright © 2010