Kiesha L. Cousar SPEAKS                                                
SPEAKER REQUEST PRE-EVENT QUESTIONNAIRE

Please fill out this form completely and return to…
 c/o Kiesha L. Cousar at admin@cousarempowerment.com.

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Company/Organization: (Please provide information about the company) *
Company/Event Website *
Contact’s Name & Title *
What is your role with planning the event? *
Contact’s Address/City/State/Zip *
Contact’s Email and Phone *
Event location - (City | State | Venue) *
What is the date of the event? *
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How long is the event expected to last? *
What time and for how long will Kiesha L. Cousar speak? *
Purpose of meeting/event *
What is the topic/theme you want Kiesha L Cousar to address? 
Do you desire the presentation to be virtual or on-site? *
Required
Will there be a Q&A?
Clear selection
Will questions be vetted?
Clear selection
What is the goal and desired outcome of the presentation or workshop ? *
How many people are anticipated to attend? *
Select your budgeted range for your speaker request? 
Workshop, Retreats and Conference service fees will be determined per client consultation.
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What is the demographic profile? (SECTION 1) *
Required
What is the demographic profile? (SECTION 2) *
Required
Would you like for Kiesha L. Cousar to do a book signing at the event? *
Required
Are you interested in pre-ordering books? *
Required
If yes, select the title(s) of interest.
If you selected "Sister to Sister: Guide for African American Girls", please state the quantity required.
If you selected "BOLD Faith: Young Adult Women Arise 21-Day Devotional Vol. 1," please state the quantity required.
What type of service setting will be utilized for the requested services? *
Required
What type of professional speaker service would you like Kiesha L. Cousar to provide? *
What type of speaker format is requested?
Clear selection
Do you desire for Kiesha L. Cousar to facilitate a workshop in addition to a keynote? *
Required
How many times do you require a workshop facilitation? *
How many participants are expected to be in attendance at the workshop? *
If you selected panel discussion, please provide the panel moderator's name and organization? 
If you selected panel discussion, please provide the title of the panel.
Event Sponsor?
Primary Event Sponsor/Host 
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How long has the event been in existence?
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Event Agenda-Website/URL 
Additional invited or confirmed speakers (Name and Organization) 
Are media representatives invited?
Clear selection
If  "yes" above, please provide the details.
Is event open to the public?
Clear selection
Will the event be recorded, broadcast or streamed?
Clear selection
If "yes" above, please provide the website to access the recording or streaming. 
Is it an audio stream or broadcast?
Clear selection
Is it a video stream or broadcast?
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If you answered "yes" to either, how will the recording be purposed?
Will there be a photographer onsite for the event?
Clear selection
If you answered "yes" above is there a photo approval/release form?
Clear selection
Are there any sensitive issues that Kiesha L. Cousar should be aware of and topics that should be avoided?
What are some of the current problems/challenges/issues experienced by your attendees, industry, organization, association or people? *
What are three concepts or take-a-ways that Kiesha L. Cousar can deliver that will allow your attendees, industry, organization, association or people to maximize their performance? *

**DISCLAMIER** By typing your first and last name, you acknowledge that you have read the following information. COUSAR Empowerment, LLC desires to meet your expectations and bring the most value to your audience.  Therefore, to book KIESHA L COUSAR Speaker Services, for a keynote speech for your upcoming event, please contact COUSAR Empowerment, LLC at least five (6) weeks prior to your event.  However, in the event that you book KIESHA L COUSAR Speaker Services for a keynote speech less than six (6) weeks prior to your event, please note additional fees shall be incurred. Furthermore, a 50% retainer fee is due upon execution of the contract and the remaining balance is due the day of the event, prior to the Speaker's Delivery. 

**DISCLAMIER** By typing your first and last name, you acknowledge that you have read the following information. COUSAR Empowerment, LLC can customize a keynote speech tailored specifically for your audience.  Therefore, if you would like to book KIESHA L COUSAR SPEAKER SERVICES, for a customize keynote speech for your upcoming event, please contact COUSAR Empowerment, LLC at least nine (9) weeks prior to your event.  However, in the event that you book KIESHA L COUSAR Speaker Services for a customize keynote speech less than nine (9) weeks prior to your event; please note additional fees shall be incurred.  Also a 50% retainer fee is due upon execution of the contract and the remaining balance is due the day of the event, prior to the Speaker's Delivery.  

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