Speaker Request Form - Jamillah Karim, PhD
Thank you for your interest in a speaking engagement with Jamillah Karim. Kindly complete this form so that I can better serve you. If I do not contact you within three days of submitting form, please email me at kjamillah@gmail.com.
Organization Sponsoring Event (specify department or student group if applicable)
Your answer
Organization Website
Your answer
Contact Name and Email
Your answer
Event Date
Your answer
Is the date flexible?
Event Title
Your answer
Event Location
Your answer
Expected Number in Attendance
Your answer
Audience Type (age, religion, ethnicity, etc.)
Your answer
Event Type (conference with multiple talks; single speaker; book reading and signing; panel; other)
Your answer
Speaker type (keynote; moderator; panelist; presenter; host; other)
Your answer
Number of Presentations
Your answer
Length of Presentation(s)
Your answer
Presentation(s) Topic/Title
Your answer
How many nights will lodging be provided?
Your answer
Will all meals be provided/reimbursed for the duration of travel?
Your answer
Will airfare be provided?
Your answer
If speaker drives, will gas and cost for rental car be reimbursed? Is there a maximum for reimbursement?
Your answer
Honorarium Amount (If no honorarium is offered, please enter zero)
Your answer
Will copies of speaker’s book(s) be available for sale? Which book(s)?
Your answer
Provide any other information or explanation here.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms