Speaker Inquiry Form

Speaker Inquiry Form
Thank you in advance for taking the time to tell me about your event.

Our Public Relations Team will get back to you shortly with the next step.

Please complete the form below by choosing appropriate boxes of interest to you and your organization.
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 Niya - Radio, Television, Podcast, Summit, Other (one time interview or a series)Be Interviewed by NiyaA Guest Appearance at your Event
About Your Organization
Name of Organization*
Contact Person*

First NameLast Name
Website Address
Industry or Profession
Email Address*
example@example.com
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Event Date

MonthDayYear
Date
Event Time

:HourMinutesAM/PM Option
What is the Theme/Topic of your Event?
Self Empowerment

InspirationalMotivationalEmpowermentMindfulness Mindset and Mind Shift
Wellness Based

Health and HealingHolistic Nutrition basedHolistic Diabetes NutritionHolistic Approaches - Integrative
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.
Is there anything else you wish to share with us about your event that you think we should know?
Should be Empty: