Speaker Request Form
Name (First Name/Last Name) *
Street Address *
City | State | Zip Code *
Phone number (include area code) *
Email *
Date of Event (mm,dd,year) *
Time of Event (Example: 3 p.m.) *
Name of Event *
Expected Number of Attendees
What kind of event? *
Required
What is your speaker/presenter budget? *
What kind of appearance would you like Dr. Yolanda Jerry to make?
Are there any sensitive issues I should be aware of or topics I should avoid? (Yes/No) Include the sensitive issue in your response
What are some of the current problems/challenges/breakthroughs experienced by your attendees, industry, organization, association or people? *
What specific topics would you like for Dr. Yolanda Jerry to address? *
Required
Is Dr. Yolanda Jerry able to set up a table for products/information at this event? *
Any additional comments or information you would like for me to consider?
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