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Speaking Request Form
Please take a few minutes to fill out this speaking request form so Dr. Mayfield can discern if this is a good fit. Expect to hear back within ten days of this request.
15
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1
Your name
*
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First Name
Last Name
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2
Your email
*
This field is required.
example@example.com
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3
What topic would you like him to speak on?
*
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4
What are the dates and times of this event?
*
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5
What type of event or organization is this for? (if there is a website please include a link)
*
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6
Approximately how many people will be present?
*
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7
How long would you like him to speak for? (be as specific as possible)
*
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8
What would appropriate dress be for this event?
*
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9
Approximately how much are you offering as an honorarium?
*
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10
Are you interested in hearing about coaching and organization consulting he offers?
*
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11
Location of event or organization:
*
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12
If out of town are you willing to pay for his transportation and hotel?
*
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13
Event contact/s:
*
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14
Email/s:
*
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15
Anything else he should know as he considers this request?
*
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