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Speaker Request Form
Please fill out this form to give us information about what we can expect with your event. Upon filling it out, we will reach out to connect with you to see if it's a mutual fit.
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Organization Name
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Contact Name
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Contact Phone
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Contact E-mail
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Date of event
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Location of event
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Name of event
Your answer
What is the theme/purpose of the event?
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Is there a specific topic you had in mind for this workshop session?
Top 3 Ways to Prevent Burnout
From Stress to Success
Building Your Personal Board of Directors
Ignite Authenticity
Other:
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Time of speaker's presentation
Time
:
AM
PM
Length of presentation
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Onsite or Virtual
Onsite
Virtual
Both
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Presentation Format
Keynote
Breakout session
Panel
Interactive workshop
Other
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Approximate Audience Size
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Give a brief description of the audience (in general....age, gender, occupation, etc.)
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Budget (Range)
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Additional comments or questions:
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