Speaker Inquiry Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Name of Organization
*
Are you the decisionmaker?
*
Yes
No
Organization Type
*
Corporation
Small Business
Non-Profit
K-12
Higher Education
Faith-based
Other
Organization's Website
*
Name of Event
*
Event Date
*
Event Theme
*
Type of Event
*
Professional Development
Personal Development
Business Development
Student Development
Fundraiser
Banquet or Other Special Event
Ministry Event
Other
Type of Presentation Requested (select all that apply)
*
Panelist
Keynote (up to 45 minutes)
Breakout Session (up to 75 minutes)
Workshop (90 minutes - 3 hours)
1/2 Day Seminar (4 hours)
Full Day Seminar (4-7 hours)
Audience (select all that apply)
*
New or Aspiring Entrepreneurs
Experienced Entrepreneurs
Women
Men
Faculty and/or Staff
Students
Mid-level Managers
Executive Leaders
Other
Age Range (select all that apply)
*
18-25
26-35
36-45
46-55
56-64
65+
Anticipated Audience Size
*
Less than 50
51-100
101-200
201-500
500+
Speaker Budget
*
Under $3500
$3501 - $5000
$5001 - $7500
$7500+
Will there be other speakers?
*
Yes
No
Do you plan to purchase copies of any of Dr. Cherita's books?
*
Yes
No
Let's discuss wholesale pricing
How did you hear about Dr. Cherita?
*
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