*EVENT DATE:

    *EVENT NAME:

    *EVENT CITY:

    EVENT VENUE:

    EVENT WEBSITE:

    EXPECTED ATTENDANCE (demographic):

    AUDIENCE DESCRIPTION:

    EVENT DESCRIPTION:

    WHAT DO YOU HOPE TO ACCOMPLISH?

    PROPOSED SPEAKING SCHEDULE:

    HONORARIUM AMOUNT:

    *CONTACT NAME:

    *CONTACT PHONE:

    *YOUR EMAIL:

    CONTACT FAX:



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