Shamyra's Speaker Request Form

SPEAKER BOOKING FORM

Thank you for your interest in booking Shamyra, also known as Sexologist Shamyra. Please complete this form in its entirety. Shamyra will contact you within 48 hours to discuss your booking request.
Your Full Name:*

PrefixFirst NameLast Name
Your Email Address:*
Company/Organization Name*
Your Contact Number*
Name of Event*
Date of Event*
Address of Location*
Time of Event*
Ex: (1pm or 8am)
Type of Event*
Ex: (1pm or 8am)
Expected # of Attendees*
What is Your Speaker Budget?*
How Would You Like Shamyra to Contribute to Your Event?*

Keynote SpeakerWorkshop FacilitatorTrainerPanelistPodcast GuestSocial Media GuestTV Show GuestOther
How Long Will You Need Shamyra to Speak?*
What Topic Would You Like Shamyra to Speak On?*
Will Shamyra be Able to Promote Any of Her Products/Services?*

YesNoLet's Talk About it!
Will Travel and Lodging Accommodations be Needed? Please Keep in Mind that Shamyra is Located in Baton Rouge, Louisiana.*

YesNoN/A
Will Travel and Lodging Accommodations be provided for Shamyra's Assistant?*

YesNoN/A
Is there any additional information you would like Shamyra to know or Consider?:
Should be Empty:

SPEAKER BOOKING FORM