Dr. Tekemia Dorsey's (DTD) Speaking Inquiry Form

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*

First NameLast Name
Email of Organizer/Point of Contact*
example@example.com
Cell Phone Number of Organizer/Point of Contact*
Please enter a valid phone number.
Organization/Company Name
Organization/Company Website
Decision-Maker Information
Event Name*
Event Purpose*
Event Start Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Event End Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Event Time Zone*
Event Location/Venue (Physical or Virtual)*
Event Type*

In-personVirtualHybrid
Agenda Request
Desired Format*

KeynoteWorkshopPanel DiscussionQ&A Session
Proposed Topic/Theme
Session Length & Q&A Time
Speaker’s Role*

Introducing Someone ElseModeratingMain 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

ReliableUnreliableUnknown
Onsite Support Contact Name
Speaker Fee/Honorarium Budget
Travel Arrangements

Host BookingSpeaker Billing
Expenses Coverage

HotelFlightMeal
Products/Book Sales Option

YesNo
Other Speakers
How They Heard About You
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.
Organization or Affiliation (if applicable)
Event Name*
Event Date*

MonthDayYear
Date
Event Location (Venue or Virtual Platform)*
Brief Description of the Event*
Estimated Audience Size
Requested Speaking Topic(s) or Focus Areas
Additional Comments or Special Requests
Should be Empty: