KMI Speaking Engagement Request Form

Speaking Engagement Request Form

Principled Leadership. Strategic Clarity. Enduring Impact.
Purpose: This form supports event planners and organizational partners in requesting a keynote, workshop, or facilitated leadership experience with Karlene Millwood International. Submissions help us assess alignment, audience needs, and event design.
Organization & Event Information
Organization / Host Name:*
Sector:*

Public Sector / GovernmentCorporate / PrivateNon-Profit / Mission-DrivenFaith-BasedAssociation / EducationOther: __________________________
Website:*
Event Name (if applicable):*
Event Type:*

ConferenceLeadership SummitInternal Offsite / RetreatExecutive MeetingWebinar / Virtual EventOther
Event Date:*
Location (City or Virtual):*
Primary Contact
Primary Contact Name:*

First NameLast Name
Title:*
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Engagement Type
Which format are you considering? (Select all that apply)*

Breakout Session (45 minutes)Panel Moderation / FacilitationLeadership Workshop (90 minutes – facilitated working session)Signature Keynote (60 minutes)Leadership Intensive (Half Day)Full-Day Transformation ExperienceNot sure — seeking guidance
Audience Profile
Estimated Audience Size:*
Primary audience level:*

Executive / C-SuiteSenior LeadersManagersMixed levels
Audience Context or Industry:*
Goals & Outcomes
What outcomes would you like this session to support?*

Leadership capabilityStrategic clarity / planningEthical decision-makingCulture or trust-buildingLeadership advancement / inclusionTeam alignmentInspiration & thought leadershipOther
Briefly describe the current challenges or priorities:*
Event Design & Logistics
Preferred format:*

In-personVirtualHybrid
Time allotted for session:*
AV or facilitation considerations (if known):*
Investment & Timeline
Budget range (helps determine fit and scope):*

$3K–$5K$7.5K–$10K$15K+$20K+$25K+To be confirmed
Decision timeline:*

Within 2 weeks1–2 months3+ months
Additional Information
Anything else we should know to design the most effective engagement?
Next Step

Upon review, our team will follow up to confirm availability and discuss the most appropriate format and scope for your event.Thank you for your interest in partnering with Karlene Millwood International Inc.
Karlene Millwood International Inc.

Principled Leadership. Strategic Clarity. Enduring Impact.
Should be Empty:

Speaking Engagement Request Form

Organization & Event Information

Primary Contact

Engagement Type

Audience Profile

Goals & Outcomes

Event Design & Logistics

Investment & Timeline

Additional Information

Next Step