Event Form

SPEAKING ENGAGEMENT INFORMATION FORM

* Indicates required field

Primary Contact Name *

Email *

Phone *

Organization/Institution *

Event location *

Event date (or date range) *

Proposed topic and format (i.e. keynote, on-stage conversation, panel, workshop, etc) *

How many people do you expect to attend? *

Proposed schedule (with additional activities requested, if any; eg: book signing, meal, classroom visit; please clearly indicate optional vs required duties) *

Books to be ordered (title/s and quantity): *

Book vendor for onsite sales: *

Honorarium Fee *

Airfare *

Yes No

Ground Transportation *

Yes No

Hotel Accommodations *

Yes No

Nearest airport *

Any additional information you'd like to share about the organization/institution, the audience, or the event. *

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