Speaker Request Form

Speaker Request Form

Please submit speaking requests at least one month prior to the event and allow at least a week for a decision to be made. If you have any problems completing or submitting this form, e-mail livelivenetwork@gmail.com.
What type of speaking are you interested in?

Keynote - full dayKeynote - multiple daysMastermind - half day/eveningMastermind - multiple daysRetreat SpeakerParticipate as part of an Expert PanelMaster of Ceremonies - emcee your eventHost/Co-host your eventAward PresenterSpeaker at your Product Launch (endorsement)Interview Michelle - Radio, Television, Podcast, Summit, Other (one time interview or a series)Be Interviewed by MichelleA Guest Appearance at your EventTrainer
About Your Organization
Name of Organization
Contact Person

First Name Last Name
Website Address
Industry or Profession
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address
example@example.com
Name

First Name Last Name
Phone Number

Area Code Phone Number
Event Date

MonthDay Year
Date
Event Time

:Hour Minutes AM/PM Option
What is the Theme/Topic of your Event?
Event's Title and Type of Event
Address of Venue

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Estimated number of attendees?
Please provide a link to your event’s website (alternatively please attach a draft agenda / program)
Empowerment

InspirationalMotivationalEmpowermentMindfulness Mindset and Mind ShiftLeadershipInvestmentVisualizationEvolution
Wealth & Financial

How to Create Wealth & Financial Freedom (Business or Personal)
Is your event sponsored? If so, please provide details
What do you want your audience to take away and really get out of this event? This helps me to customize my presentation for your event to meet your goals and objectives.
What is the average revenue of your audience members?

$50,000 - $75,000 per year$76,000 - $100,000 per year$101,000 - $150,000 per year$151,000 - $250,000 per year$251,000 - $500,000 per yearOver $500,000 per year
What is your budget? (including travel & accommodations)
Is there anything else you wish to share with us about your event that you think we should know?
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform