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Dr. Victor Santiago Pineda - Speaker Request Form
Thank you for considering Dr. Victor Pineda as an seasoned inspirational speaker or subject matter expert for your event.
Please read the following before filling out this form:
You can learn more about the topics and impact of Dr. Victor Santiago Pineda here
.
Please review the
presentation
and prepare any questions you may have.
To further understand your needs, please fill in the following fields below and a member of our team will be in touch.
For more information please email jothie@pinedafoundation.org.
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Contact Name
*
Your answer
Contact Email Address
*
Your answer
Engagement Type
*
Select all that may apply
Paid Speaker: Keynote speaker
Paid Speaker: Featured speaker
Paid Speaker: Featured panelist
Interview: Radio or podcast feature (Individual)
Interview: Radio or podcast feature (Subject Matter Expert)
Interview: Television or video interview
Other:
Required
Event Name
*
Your answer
Event Location
*
Your answer
Event Theme/Title
*
Your answer
Audience Size
*
Your answer
What impact you seek to create from the engagement.
*
Your answer
Organization Name
*
List the name of the sponsoring organization or client.
Your answer
Event Location (Physical Address or Virtual Platform)
*
Your answer
Event Start & End Dates
*
Your answer
Preferred Speaking Date (if available)
MM
/
DD
/
YYYY
Preferred Speaking Time (if available)
Please include the timezone
Your answer
Do You Have a Speaker Budget Allocation for this Event? If yes, please state the value.
*
Dr. Pineda is a highly sought after speaker and cannot accommodate unpaid speaking fees.
$50,000 - $25,000
$25,000 - $15,000
$15,000 - $7,500
Less than $7,500
Agenda/Program URL or flyer
Your answer
Do you intend to broadcast or record the speech?
*
Please note that Dr. Pineda requires recorded speeches to be captioned and made accessible for all.
Yes
No
Other:
Logistics Coordinator Name & Email
*
This could be the event curator, producer, or communications lead that manages speaker contracts.
Your answer
Procurement Coordinator Name & Email
*
This is the person responsible for executing contracts or billing.
Your answer
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