Name:

Title:

Company:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email Address:

Speaker's Biography:

Presentation Structure (Panel--Brand Marketer Case Study--Research/Market Update):

Presentation Title and Description:

Five Key Benefits of Presentation:

Additional Panelists to be Considered (Name, title and affiliation):

PRIMARY POINT OF CONTACT
Who should we contact with questions about the proposal?

Name:

Phone:

Email:

Please select which IAB Events you would be interested in speaking at:

 Leadership Forum Direct Response, March 2006, Chicago, IL

 Leadership Forum Broadband and Beyond, May 2006, New York, NY

 MIXX Conference and Expo, September 2006, New York, NY

 IAB Ad Operations Summit, October 2006, New York, NY

 IAB Annual Member Meeting, October 2006, New York, NY

 Leadership Forum Agency Summit, November 2006, New York, NY