Speaking and Special Appearance Form
Kathy Amos Coaching & Consulting LLC.
Full Name
*
First Name
Last Name
Name of Organization
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Website
How did you hear about Dr. Kathy?
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Newspaper
Internet
Magazine
Other (Please specify...)
Speaking | Special Appearance
Please answer the questions below.
Which are you booking for:
Speaker/Moderator
Speaker/Trainer
Speaker/Coach
Date of the event
-
Month
-
Day
Year
Date of the event
Start time of the event
Time of the event Minutes
AM
PM
AM/PM Option
End time of the event
Time of the event Minutes
AM
PM
AM/PM Option
Address to Event Venue
Name of the Event:
Event Theme (if any):
Brief Description of Event:
If speaking, is there a specific topic you would like Dr. Kathy to use? Give a brief description.
If this is a moderating opportunity, please give details of responsibilities for session.
How many guests do you anticipate on having in person or virtual?
Is the event online or onsite?
Who long will Dr. Kathy be needed to speak, train, etc?
Please Select
15 minutes
30 minutes
1 hour
Half Day Workshop/Training
Full Day Workshop/Training
Other
If other, please explain.
Check any items needed from Dr. Kathy
Headshot
Short Bio (up to 150 words)
Long Bio (up to 300 words)
Other
If other, please describe
Dr. Kathy may be compensated for the following should the need arise. Please check all that apply.
Lodging
Travel (check this box if event is more than 50 miles from Canton, MS. Send details to email at info@bemississippi.com)
Meals
Not Applicable
A security deposit of half of the speaker’s fee is required to book the date of your event. Please secure your date below.
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Approved Deposit
Deposits Range From $250 to $1500 and is approved by Dr. Kathy Amos.
Free
$
Free
Security Deposit Requested
250
500
750
1000
1250
1500
Speaker's Fee (Payment in Full)
Free
$
Free
Speaking Time
Small Church or Ministry (On-site): $500
Payment in Full for 60 Minutes Onsite: $1000
120 Minutes Onsite: $1,500
Half-Day Training/Workshop $2,500
Full Day Training/Workshop $5,000
Payment Methods
Credit Card
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
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