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Speaker Request Form
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Please select your Event Type
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Cheque Presentation
Community Group Presentation
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Police and Emergency Services
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What type of Speaker best meets the needs of your event?
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Virtual Speaker
In-Person Speaker
Pre-recorded Virtual Speaker Video
Event Details
Event Name
On what date is your event scheduled?
The Speakers Team requires a minimum of 30 days to process each Speaker Request to identify an appropriate and available Speaker.
Event Address
Start Time of the Event
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11:00 PM
11:15 PM
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11:45 PM
End Time of the Event
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12:00 AM
12:15 AM
12:30 AM
12:45 AM
1:00 AM
1:15 AM
1:30 AM
1:45 AM
2:00 AM
2:15 AM
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2:45 AM
3:00 AM
3:15 AM
3:30 AM
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5:00 AM
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6:00 AM
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6:45 AM
7:00 AM
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8:00 AM
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8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
6:15 PM
6:30 PM
6:45 PM
7:00 PM
7:15 PM
7:30 PM
7:45 PM
8:00 PM
8:15 PM
8:30 PM
8:45 PM
9:00 PM
9:15 PM
9:30 PM
9:45 PM
10:00 PM
10:15 PM
10:30 PM
10:45 PM
11:00 PM
11:15 PM
11:30 PM
11:45 PM
Is the event date and time flexible?
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Yes
No
Expected number of guests
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Audience demographic
Briefly describe who is attending the event and what mental health experience you would like to hear about.
Length of presentation required
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20 - 30 mins
30-40 mins
40-50 mins
Time selected includes Speaker presentation and Q&A’s
Organisation Contact Details
First name
Last name
Position at Organisation
Mobile Number
Business Number
Email
Organisation Details
Organisation name
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State / Territory
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ACT
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Country
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Afghanistan
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Austria
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Belize
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Bolivia
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Bouvet Island
Brazil
British Indian Ocean Territory
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Burkina Faso
Burundi
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
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Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
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Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
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Guyana
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Heard Island and McDonald Islands
Honduras
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Japan
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Laos
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Liberia
Libya
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Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
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Maldives
Mali
Malta
Marshall Islands
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Moldova
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Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
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Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
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St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
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Sudan
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Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
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Postcode
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Please provide a brief description of your Organisation
e.g. size, demographic
What is your primary motivation and key objectives for requesting a Beyond Blue Speaker?
Any other helpful information
Is there a financial component to your event? i.e. Fundraising
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