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Speaker Request Form
Interested in having Dr. Knatokie Ford speak at your event or serve as a guest on your podcast? Please take a moment to fill out this form and provide additional details.
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* Indicates required question
Email
*
Your email
Event Point of Contact
*
Your answer
Event Point of Contact preferred honorific (e.g., Ms., Mr., Dr.)
Your answer
Organization
*
Your answer
Event Name
*
Your answer
Event Location
*
Your answer
Event Date
*
MM
/
DD
/
YYYY
Is the event open to press?
*
Yes
No
Required
Will the event be live streamed or recorded?
*
Live streamed
Recorded
TBD
Required
Anticipated audience size and types of attendees
*
Your answer
Requested speech topic
*
Your answer
Type of Speaking Request
*
Panelist
Moderator
Keynote (15-25 mins)
Keynote (30 mins - 1 hour)
Podcast Guest
Other:
Required
For Panels: Is an honorarium offered?
*
Yes
No
Not applicable
For Keynotes: Are you able to pay speaker fees and/or interested in information on rates?
*
Yes
No
Not applicable
Other:
For Keynotes: What is your speaker budget?
*
Your answer
Will travel expenses be covered?
*
Yes
No
N/A [for virtual events]
Other:
Required
How did you hear about Dr. Ford?
*
Your answer
Additional Comments
Your answer
Send me a copy of my responses.
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