Speaker Request Form
This form is to request Dr. Miller to speak at your next in-person or virtual event. If the event is outside of Cincinnati, Ohio, and the surrounding metropolitan area, please account for Dr. Miller's required travel expenses, including air travel, ground transportation, and lodging for the duration of the engagement. For local engagements within Cincinnati, Ohio and surrounding areas, ground transportation costs are also required. Travel expenses are in addition to the speaking honorarium.
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
Will an Honorarium be Provided?
*
Yes
No
Will Hotel and Travel Expenses be Reimbursed?
*
Yes
No
Number of Speaking Sessions Requested
*
Please List The Day(s) and Time(s) You Would Like to Speak
Will There be a Resource Table Available?
*
Yes
No
Additional Relevant Information or Requests
Submit
Should be Empty: