Mia Wilson Speaker Request
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Email *
Contact's Name & Title: *
Contact's Phone:
What is your role with planning the event: *
Organization/Event Information
Company/Event: (Please provide the company/event name as well as high level information about the company/event.) *
Company/Event Website: *
Who in your organization is responsible for signing contracts? *
Event Location: (City, State, Venue) *
Event Date? Date & Time Mia would speak? *
Purpose of meeting/event: *
How many people will attend? *
What exactly would you like Mia to do? *
What topic would you like Mia to address? *
Demographic & Profile of group(s) to be spoken to:
Is there more than one appearance requested?
How long would the presentation last?
Budget & Travel Information
Please Note: Mia will be traveling from Greensboro, NC.
What is your budget? *
 What is the closest airport?
Is travel/lodging included for the speaker?
Will ground transportation and meals be provided?
Additional Comments
Anything else you'd like for us to know?
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