Your Full Name:
Your Email Address:
Company Name:
Primary Website:
Street Address:
Street Address, Line 2:
City: State: Postal Code:
Telephone #
Alt. Telephone # [optional]:
Date(s) of presentation [enter in any format]:
Geographic Location (City/State/Country):
Anticipated audience size:


Briefly describe the purpose/function at which you would like me to speak. Include what you would like to accomplish by having me there.. We will, of course, go into far greater detail in subsequent correspondence via telephone:

 

All information submitted via this form will be kept strictly confidential. You are under no obligation to accept any proposal given. If you decide to hire me to speak, a detailed written agreement reflecting the interests of all parties involved will be forwarded to you shortly thereafter. Rates vary according to project.