Welcome

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

What topic would you like him to speak on?* This field is required.

5

What are the dates and times of this event?* This field is required.

6

What type of event or organization is this for? (if there is a website please include a link)* This field is required.

7

Approximately how many people will be present?** This field is required.

8

How long would you like him to speak for? (be as specific as possible)** This field is required.

9

What would appropriate dress be for this event? ** This field is required.

10

Dr. Mayfield's typical price for a weekend event is $5500. Is there an an honorarium? If so Approximately ho much? * This field is required.

11

Location of event or organization: ** This field is required.

12

If out of town are you willing to pay for his transportation and hotel? ** This field is required.

13

Event contact/s:Email/s:** This field is required.

14

Anything else she should know as he considers this request? * This field is required.