Speaking Engagement Request Form

Speaking Request Form
Thanks so much for your interest in having the BlinkNow story be a part of your event! Please note that Maggie Doyne, our co-founder and CEO, has a very busy schedule and is not able to accommodate all requests. If she isn't available for your event, we're happy to discuss having another member of BlinkNow attend. Please do keep in touch with us via Press@BlinkNow.org.
Today's date*

MonthDayYear
Contact Information
Host organization:*
Organization website:*
Contact name:*

First NameLast Name
E-mail:*
Phone number:*

Area CodePhone Number
About the organization:*
Your name:

First NameLast Name
Email address:
Event Details
Event name:*
Date of Event*

MonthDayYear
Date
Venue name:*
Event theme:
Event type:*

EducationalCorporateFundraiserOther
Please describe the complete timetable of the event.
Speech topic
Are there any additional outside speakers participating in this event?*
Please list any previous speakers:*
About the event:*
Audience profile (include estimated # of attendees):*
Media requests:
Are you requesting to record any part of the presentation?*

Yes, audio-only of the presentationYes, video of the presentationNo, no recordings are planned
Will tickets for your event be sold to the public?*

YesNo
Speaker attire (indicate one):*

CasualBusiness CasualBusinessBlack Tie
Audience attire (indicate one):

CasualBusiness CasualBusinessBlack Tie
Venue address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Travel & accommodation details:*
We ask that every speaking engagement pay for Maggie's travel from Nepal (est. $3,000 USD) as well as accommodation near the event location.
Other Information
We’re so glad you're interested in sharing the BlinkNow story! Our founder & CEO Maggie Doyne has a full schedule with limited availability. Would you be interested in having another BlinkNow representative speak at your event instead?

Yes! Please send me details on another speaker.I'm not sure.No, we prefer to have Maggie herself at the event, if possible.Other
Has Maggie spoken for your organization in the past?*

YesNo
Please note: we ask for an honorarium for each speaking engagement. Should your request be accepted, we'll be in contact about the amount.
Anything else you'd like us to know?
Should be Empty:

Speaking Request Form

Contact Information

Event Details

Other Information