Dr. Tekemia Dorsey's (DTD) Speaking Inquiry Form
Submit your request to invite Dr. Tekemia Dorsey as a speaker at your event.
Name of Organizer/Point of Contact
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First Name
Last Name
Email of Organizer/Point of Contact
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example@example.com
Cell Phone Number of Organizer/Point of Contact
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Please enter a valid phone number.
Format: (000) 000-0000.
Organization/Company Name
Organization/Company Website
Decision-Maker Information
Event Name
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Event Purpose
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Event Start Date & Time
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Month
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Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Event End Date & Time
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Month
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Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Event Time Zone
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Event Location/Venue (Physical or Virtual)
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Event Type
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In-person
Virtual
Hybrid
Agenda Request
Desired Format
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Keynote
Workshop
Panel Discussion
Q&A Session
Proposed Topic/Theme
Session Length & Q&A Time
Speaker’s Role
*
Introducing Someone Else
Moderating
Main Speaker
Recording/Live Streaming Details
Expected Attendee Count
Audience Profile (Demographics)
Audience Challenges/Needs
A/V Equipment Provided
A/V Equipment Needed
Internet Access Reliability
Reliable
Unreliable
Unknown
Onsite Support Contact Name
Speaker Fee/Honorarium Budget
Travel Arrangements
Host Booking
Speaker Billing
Expenses Coverage
Hotel
Flight
Meal
Products/Book Sales Option
Yes
No
Other Speakers
How They Heard About You
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or Affiliation (if applicable)
Event Name
*
Event Date
*
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Month
-
Day
Year
Date
Event Location (Venue or Virtual Platform)
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Brief Description of the Event
*
Estimated Audience Size
Requested Speaking Topic(s) or Focus Areas
Additional Comments or Special Requests
Submit Inquiry
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