Service Request Form
Name of Organization (If Applicable)
What service are you seeking
Keynote, Plenary, Workshop, or Panelist Speaking Engagement
Training Event (s)
Please answer the following questions to the best of your ability. If a question is not applicable to a service you're seeking, write N/A in the response area.
For trainings and speaking engagements: What are the dates and times of your event (s)?
For trainings and speaking engagements: Who is the audience for this event? How many people are you expecting? Please describe your target audience -age, faith/religion, gender/sexuality, race/ethnicity, socioeconomic background, etc.
For trainings and speaking engagements: What theme(s) would you like me to teach/speak on? What have you already done to prepare your participants toward these themes?
For trainings: How many training sessions are you seeking? How long would you like each session to be?
For 1-1 coaching, consulting, and facilitation services: What are you seeking these services for? How many sessions are you seeking?
Are you able to cover honorariums/fees associated with the service (s) you are seeking?
Yes, I am able to cover all honorariums/fees
No, I would like to discuss negotiating service rates
I am seeking pro bono services due to financial hardship
In addition to the honorarium/fee, are you be able to cover travel - standard coach rates out of Reagan National airport (preferably American Airlines)? Lodging in a single-occupancy hotel room? A $60 meal per diem (includes event days and travel days)?
All services include a $50/day late fee for payments not received by the date agreed to in service contract.
I understand and agree to this late fee
I would like to discuss this further
What date do you need a decision by about working with AnaYelsi
Send me a copy of my responses.
Never submit passwords through Google Forms.
This form was created inside of browneyedamazon.com.