SPEAKING REQUEST QUESTIONNAIRE
Thank you for your interest in having Dr. Nicole Roberts Jones as a speaker at your event or on your podcast. Please take a moment to complete the questionnaire and we will get back to you within 24 - 48 hours.
Name
First Name
Last Name
Your Email
example@example.com
Company/Organization/Group
*
Are you requesting Dr. Nicole to speak at your event or as a guest on your podcast?
*
Speaker At My Event
Be On My Podcast
Website Address
*
Primary Contact Name
*
Primary Contact Telephone
*
Primary Contact Email
*
Date of the Event (if podcast just write n/a)
*
Location of the Event (if podcast just write n/a)
*
Number of Attendees Expected To Attend Event or Listeners if a Podcast
*
Purpose of Event/Podcast: What do you want participants to walk away with?
*
Topic of Interest: What would you like Dr. Nicole to speak on?
Women's Empowerment
Entrepreneurship: Business Development or Growth
Vision/Purpose
Leadership Development
Life Balance
Thriving Through Change
Other
Tell us more about topic you are interested in
*
Who is the audience?
*
How long would you like Dr. Nicole to speak?
*
Is there an event/podcast website? (please include link)
*
What is your promotion plan? TV, Radio, Social Media, Internet, Other
*
Are you proposing to offer Dr. Nicole an Honorarium/Speaker Fee?
*
If this event is outside of the Washington DC area, what expenses have you budgeted for Nicole's travel, transportation and overnight accommodations?
*
Is this a ticketed event? If so what is the ticket price
*
Yes
No
Will this event be recorded?
*
Yes
No
If Nicole accepts, we will provide a professional high-res head shot, written and read-it bio for marketing purposes. We do not approve nor authorize any likeness to Dr. Nicole Roberts Jones or Dr. Nicole Roberts Jones photos, videos or content from the public domain (i.e. internet, social media pages, web pages, etc.) Do you agree to honor our request?
*
Yes
No
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