CBW-LA Speakers Form

CBW-LA SPEAKER FORM

Please fill out the form below to help us set up your registration page.
Name *
E-mail *
Phone Number *

Area Code Phone Number

Address *

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

Legal Name (if different from author name-this is what we will use on the check)
Author Website
Other Social Media Sites (put N/A if none)
Author Bio *
Author Photo *
Book Title *
Book Summary *
Book Cover *
Link to Buy Book
Book Price *
Proposed Workshop Date *

Month Day Year
Date
Title of Proposed Workshop *
Description of Proposed Workshop *

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