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 Name Last 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

City State / Province

Postal / Zip Code
Your Corporate Phone Number *

Area Code Phone Number
Date of Event *

Year Month Day
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

City State / Province

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

Board of Directors Talent Management/HR C-Suite Leaders Learning & Development
Who is the audience group? *

Board of Directors Executive Leaders Mid-Level Leaders and Managers Mid-Level Leaders Mid-Level Managers Subordinate Employees External Constituents
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 *

Summit Conference Commencement Church Service/Prayer Breakfast Book Signing Fashion Week Book Tour Seminar Corporate Event, Meeting, or Training Workshop Health Fair Doctoral Colloquium Festival or Exposition Radio/TV Appearance Writing Services (White Paper or Case Study) High School, Virtual School, Alternative School, College, or University
What type of talk would you like Dr. Tennin to contribue? *

Host/Facilitate Breakout Session Keynote Speaker Corporate Facilitator/ Corporate Trainer Panelist Guest Speaker Advisory Board Member Board of Directors Member White Paper or Case Study Writing Services Consulting or Advisory Service (if so, please contact Lady Mirage Global, Inc. and do not complete the remainder of this form)
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)
Which Other Talk or Corporate Training(s) would you like Dr. Tennin to cover? (Or type N/A) *

Other Talk: Entrepreneurship-Finding an Opportunity Other Talk: Entrepreneurship/Business Revitalization Projects: Constructive Feedback on How to Improve Your Business Other Talk: Career Personality Profiles - Marketing Emphasis Other Talk: Careers in General Management & Marketing Other Talk: Effective 21st Century Management/Leadership Styles Other Talk: Overcoming Adversity Other Talk: Ethics in Banking Other Talk: Change Management for Leaders Other Talk: Exploring Various Careers in the Business Field Other Talk: How to Become an Entrepreneur: Locating Opportunities Other Talk: Graduates: It's Time to Hit Your Stride! (Commencement) Other Talk: First Impressions: Your Brand Other 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 Triumph COVID-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)
How long is Dr. Tennin's talk time? (Or type N/A) *

30-minutes Full-Day Session 1-hour Several Days 90-minutes Half-Day Session
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