Guest Speaker Form

SPECIAL GUEST SPEAKER FORM

Changing lives with your mission and message.
Personal Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
Phone Number*

Area CodePhone Number
Website
Professional Information
Business/Organization*
Job Title/Position*
Professional Bio (Required Limit 300 Words)*
Social Media Handles
Upload Short Bio (150 words or less in Word or PDF format)

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PowerPoint PresentationHandoutsOther
If other, please explain
Logistics & Preferences
In-PersonVirtual
YesNo
If yes, specify event*
Confirm the Date Requested to Speak

MonthDayYear
Date
15 Minutes30 Minutes1 HourHalf Day Training/Coaching (3-Hours)Full Day Training/Coaching (6-Hours)
Speaker FeeDepositBoth
If so, please share the amount
MicrophoneProjectorOther
If other, please share
If you chose other, please share your topic and a brief description of it.
Speaker’s Topic (If Different From the Above List)
YesNo
If applicable, specify any travel-related requirements
Additional Information
Do You Have Any Products or Services to Promote?
Please upload a professional headshot for our promo flyer. All headshots are subject to approval*

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I agree to submit all necessary materials by the deadline.I agree to uphold the values and mission of the Business Empowered International Chamber of Commerce.I grant permission to use my photo and presentation materials for event promotions.
Signature*
Today's Date

MonthDayYear
Date
Business Empowered Mississippi Chamber MembershipBusiness Empowered Mississippi SponsorshipsBusiness Empowered Honors ProgramUpcoming EventsVolunteer Opportunities
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SPECIAL GUEST SPEAKER FORM

Personal Information

Professional Information

Logistics & Preferences

Additional Information