Speaker Request Form
Name (First Name/Last Name) *
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Street Address *
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City | State | Zip Code *
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Phone number (include area code) *
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Email *
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Date of Event (mm,dd,year) *
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Time of Event (Example: 3 p.m.) *
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Name of Event *
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Expected Number of Attendees
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What kind of event? *
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What is your speaker/presenter budget? *
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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
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What are some of the current problems/challenges/breakthroughs experienced by your attendees, industry, organization, association or people? *
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What specific topics would you like for Dr. Yolanda Jerry to address? *
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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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