Speaking Engagement Inquiry Form

Contact Person's Name *

First Name Last Name

Title of Event and Name of Host Organization *

Contact Person's Number *

Area Code Phone Number

Contact Person's E-mail *

example@example.com

Host Organization's Website or Facebook Page *

Host Organization's Mailing Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Speaking Topic or Theme *

If you chose Other, please indicate Topic or Theme:

What is the nature of this event? *

Date of Event *

Month Day Year Date Picker Icon

Time *

: Hour Minutes AM/PM Option

Location of the Event (Venue Name, Address, City, State, Zip Code) *

Length of presentation time: *

Will there be other speakers/presenters? *

Yes No

Audience size: *

Is there an admission fee? *

Yes No

A/V equipment available (if applicable)? *

Do you have professional sound and/or video technicians available? *

If you are recording this event, will you provide us a copy of the recording for our unrestricted use? *

Is there WiFi available? *

Yes No

Will there be a vendor table available for book/product sales? *

If no fee is indicated by the chosen Topic or Theme, a MINIMUM honorarium of $150 is requested. Also, if the event requires travel outside of my current location, the Host Organization will be responsible for travel and hotel fees (if applicable). Please let us know asap if your budget can handle these expenses. *

How will you promote and market this event? Please email any marketing materials for approval before using please. *