Candie A. Mitchell-Price Speaker Request Form
Your Name
*
First Name
Last Name
Your Contact Email
*
example@example.com
Your Contact Phone Number
Format: (000) 000-0000.
Name of Church or Ministry
*
Church or Ministry Website
*
Name of Requested Event or Conference
*
Theme(s) and/or Focus of Gathering
Date of Event
*
/
Month
/
Day
Year
Date
Expected Number of Attendees
*
Event Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Speaking Sessions Requested
*
Please List The Day(s) and Time(s) of Speaker Sessions
Honorarium*
*Honorarium is separate from travel, ground transportation, and hotel accommodations. Requested party/organization should expect to cover all aforementioned expenses.
Will There be a Resource Table Available?
*
Yes
No
Additional Relevant Information or Requests
Straight Outta Brokenness Book Tour
Panel Discussion
Meet The Author
Book Signing
Submit
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