EngageEcanoa5 Experience
Speaker Engagement Request
Ecanoa and the EngageEcanoa5 Team thanks you for your invitation. Please complete this form to request Ecanoa for your event. This form is a request for information only and should not be considered a confirmation. Upon receipt of all pertinent information, a representative from the EngageEcanoa5 team will be in contact within 2-3 business days.
Organization, Company, School, Ministry Name
Host Name
*
First
Last
Website
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Name of the Event
Type of Event
Please Select
Aim High, Miss High Experience for High School Seniors.
Training
Seminar
Conference
Panelist in a Panel Discussion
Other
Select the book title/subject you would like for Ecanoa to speak on.
Please Select
Success Built on Principles of What Not to Do
Aim High, Miss High (1st Edition)
Sticks & Stones May Break My Bones (Book & Workbook)
Questions
Select the time range allotted for the speaker
Please Select
No More than 30 Minutes
30-45 Minutes
45-60 Minutes
Please indicate if this request is for one day or multiple dates:
Please Select
Request for one day
Request for multiple dates
Enter the Requested Date or (Enter the 1st Date if multiple dates are requested)
Event Start Time
Hour Minutes
AM
PM
AM/PM Option
Event End Time
Hour Minutes
AM
PM
AM/PM Option
Event Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the closest Major Airport to the event location?
What is the approximate distance, in miles, from closest major airport to event location (required for events outside of Georgia)?
Anticipated Attendance for the Event
Please Select
< 50
51 - 100
101 - 200
201 - 300
301 - 400
401 - 500
500 +
Will this engagement be broadcast live via the Internet or television?
Please Select
Yes
No
Do you allow the sale of media products?
Please Select
Yes
No
Additional event details (e.g., theme, multiple dates, event type, etc.)
Names of other participating speakers and their speaking dates and times:
Primary Contact Information
Please provide the name and information for the person who will be our primary contact.
Contact Person
First Name
Last Name
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.
Contact Alternate Phone
Please enter a valid phone number.
Submit
Should be Empty: