Dr. Chisholm Speaker Form
Please tell us about your event by answering the following questions below. We look forward to working with you. Have an amazing day!
Your Full Legal Name *
Your Email Address *
Your Phone Number *
Your Mailing Address
Are you contacting JuanChisholm.com on behalf of a speaking engagement? *
If your response was "yes" above, please share with us the details about the event (i.e., date, time, location, purpose of event, etc)? If your response was about having Dr. Chisholm write a news column, please share the information in the box below.
If unsure about the details of the event, please type "unsure" in the box below.
What category of speech would you like to hear? *
Please choose one of the following categories from Dr. Chisholm's "Ten (10) Degrees of Speaking Series"
What is your budget for this event?
What is the title, position, or capacity you are contacting us in? Please be as specific as possible.
Please skip this question if it does not apply to you.
Other Objective and Goals: Please discuss what you would like us to help you accomplish as part of this process. You may want to include your response to the following optional questions to help you reflect on your other objectives or goals: 1) What do you think you may need assistance or guidance on? Alternatively, (2) how do you think we can help you achieve your goals?
Please try your best to describe the nature of your problem or concern to us.
Would you like to order books or printed material with the requested service provided?
Clear selection
Is there anything that you have not said that you would like us to know?
If you have said everything that you would like to say, simply type "No."
BEST TIME TO CONTACT YOU: What is the best day to reach you?
1st Choice
Clear selection
BEST TIME TO CONTACT YOU: Around what time? Please provide us with at least a 3 hour window.
i.e., 9a-12 noon; between 1 and 4
BEST TIME TO CONTACT YOU: What is the best time to reach you?
2nd Choice
Clear selection
BEST TIME TO CONTACT YOU: Around what time? Please provide us with at least a 3 hour window.
i.e., 8am-11am; 2:30pm-5:30pm
How did you hear about us? *
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