Speaker Request Form

SPEAKING AND/OR WRITING REQUEST QUESTIONNAIRE

Thank you so much for considering Dr. Kyla L. Tennin, D.M. for your next event or project. Each of her speaking and writing categories, topics, and event types are purposeful, derive from deep personal, professional, board of directors, and business advisory experience. Please complete this form to request her for a speaking or writing engagement, appearance, or corporate training and we will respond within 3-5 business days.
Name*

First NameLast Name
Job Title and Department Name*
Company Name*
Company Website*
Your Corporate Email Address*
example@example.com
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Corporate Phone Number*

Area CodePhone Number
Date of Event *

YearMonthDay
Date
Will the event require multiple days? Type yes or no.*
Event Address (otherwise leave blank if event is virtual)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Conference/Event or Corporate Training and Theme*
Department name the event will be held in?*

Board of DirectorsTalent Management/HRC-Suite LeadersLearning & DevelopmentOther
Who is the audience group?*

Board of DirectorsExecutive LeadersMid-Level Leaders and ManagersMid-Level LeadersMid-Level ManagersSubordinate EmployeesExternal ConstituentsOther
Will the conference/event, appearance, or corporate training be local, regional, national or interational and "in-person"? Or will it be "virtual"? (Or type N/A)*
Is your organization planning to record the event? (Or type N/A)*
Does the event need to be recorded? (Or type N/A)*
Can Dr. Tennin recruit someone to record portions of the event, testimonials, or take a photo of her speaking at the event (e.g. 3-5 minute recording for her archives)? Type yes or no in the box. (Or type N/A)*
Expected Number of Attendees*
Event Type*

SummitConferenceCommencementChurch Service/Prayer BreakfastBook SigningFashion WeekBook TourSeminarCorporate Event, Meeting, or TrainingWorkshopHealth FairDoctoral ColloquiumFestival or ExpositionRadio/TV AppearanceWriting Services (White Paper or Case Study)High School, Virtual School, Alternative School, College, or UniversityOther
What type of talk would you like Dr. Tennin to contribue?*

Host/FacilitateBreakout SessionKeynote SpeakerCorporate Facilitator/ Corporate TrainerPanelistGuest SpeakerAdvisory Board MemberBoard of Directors MemberWhite Paper or Case Study Writing ServicesConsulting or Advisory Service (if so, please contact Lady Mirage Global, Inc. and do not complete the remainder of this form)Other
Which Keynote Talk (a.k.a. Signature Talk) or Writing Service would you like Dr. Tennin to cover?*

Keynote Signature Talk (Overcoming Adversity: Surviving Corporate Betrayals (A 10-Year Journey))Keynote Signature Talk (Overcoming Adversity: Surviving [Friendship] Betrayals (A 10-Year Journey))Keynote Signature Talk (Overcoming Adversity: Surviving Economic Crises (A Journey to Recovery))Keynote Signature Talk (Overcoming Adversity: Surviving Familial Abuse (A 10-Year Journey))Keynote Signature Talk (Overcoming Adversity: Surviving Relationship Abuse (A 3-Year Tumul tuous Journey))Keynote Signature Talk (Overcoming Adversity: Surviving Homelessness (Cars, Gas Stations, Winter Weather, Academic Degrees, & Fast Food Restaurants))Neither (This talk is an Other Talk or Corporate Training - select one below)Writer (White Paper)Editor (White Paper)Writer (Case Study)Editor (Case Study)Other
Which Other Talk or Corporate Training(s) would you like Dr. Tennin to cover? (Or type N/A)*

Other Talk: Entrepreneurship-Finding an OpportunityOther Talk: Entrepreneurship/Business Revitalization Projects: Constructive Feedback on How to Improve Your BusinessOther Talk: Career Personality Profiles - Marketing EmphasisOther Talk: Careers in General Management & MarketingOther Talk: Effective 21st Century Management/Leadership StylesOther Talk: Overcoming AdversityOther Talk: Ethics in BankingOther Talk: Change Management for LeadersOther Talk: Exploring Various Careers in the Business FieldOther Talk: How to Become an Entrepreneur: Locating OpportunitiesOther Talk: Graduates: It's Time to Hit Your Stride! (Commencement)Other Talk: First Impressions: Your BrandOther Talk: Effective Leadership on Campus: The Driving Force Behind Change (for Alumni Associations)Other Talk: New Year, New You! (REAL Weight Loss & Nutrition Strategies)Other Talk: Living a Healthy You!Other Talk: How to Accomplish Your Dreams When Others Don't Want You To: Story of Abuse, Trials, and TriumphCOVID-19 & Other Corporate Trainings (Dealing with Difficult Customers; Suicide Prevention; Resiliency & Bouncing Back Stronger; The New Normal: Best Practices for Working Remotely; Stress Reduction: Relaxation Skills for the Workplace; The New Normal: Conquering Fear & Anxiety; OR Resilience in Case of Adversity or Violence)Customized Corporate Training (e.g. customized trainings Dr. Tennin creates based on the request of the organization and can include Leadership Foundations, Strategic Thinking, Creating Clarity & Focus, and Challenging Conversations)Neither (This talk is a Keynote Signature Talk - select one above)Other
How long is Dr. Tennin's talk time? (Or type N/A)*

30-minutesFull-Day Session1-hourSeveral Days90-minutesHalf-Day SessionOther
What's your speaker/trainer or writer/editor budget you are prepared to compensate Dr. Tennin?*
What professional trainers/speakers or writer/editor have you used in the past and what topics did they cover?*
Are there any sensitive issues that I should be aware of or topics that should be avoided?
What are some of the current problems/challenges/breakthroughs experienced by your attendees, industry, organization, association or people?
What are 3 concepts or strong take-a-ways Dr. Tennin can deliver that will allow your attendees, industry, organization, association or people to maximize their performance?*
Upon acceptance of your request and a formal agreement we will provide a professional high-res head shot, written, and read-it bio for marketing purposes. We do not approve nor authorize any likeness to Dr. Tennin or Dr. Tennin's photos, videos or content from the public domain (i.e. internet, social media pages, web pages, etc.) for use in any of way. Do you agree to honor our request? Type "yes" or "no" in the field and click submit.*
Thank you for submission!

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SPEAKING AND/OR WRITING REQUEST QUESTIONNAIRE