Concerned Black Men National Online Speaker Request Form

Concerned Black Men National Online Speaker Request Form
All fields must be completed to process request.

Please complete fields that do not apply with "N/A"
Select Speaker*
Other Speaker
Travel or Lodging?*

Air TravelOvernight LodgingGround Travel
Presentation Format*

Speech/Prepared RemarksPanelistInterview/(Audio/Video)
Topic/Subject of Presentation*
Occasion/Event for Remarks*
Company Type*
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Company Contact*

First NameLast Name
Company Telephone*
Contact Email*
Venue *
Venue Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Will an award be given?*
Will an honorarium/payment be awarded?*
If yes, indicate actual dollar amount (USD):
You may pay honorarium/here (optional):

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