Speaker Request Form

Your name:

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Your email:

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Event date:

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Event type:

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Number of speaking/teaching engagements:

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Schedule & duration of speaking times:

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Is Tim the main speaker?

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Other speakers (if applicable):

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Estimated number of attendees:

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Makeup of attendees:

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Organization name & mailing address:

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Contact person for event:

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Contact phone number & email:

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How did you hear about Tim Stevens?

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Overall purpose of event:

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Requested topic:

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Location & address of event:

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Will you need a headshot and bio of Tim Stevens?

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Would you be willing to provide travel accommodations for Tim to bring an additional guest?

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What typical honorarium do you provide for this event?

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