Booking Request Form
Please complete the Booking Request Form and a confirmation will be emailed to you if requested date is available.
Name of Host Organization
Address of Organization
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Point of Contact/Coordinator
E-mail Address
example@example.com
Phone Number
-
Area Code
Phone Number
Event Details
Type of Event
Conference/Retreat
Breakfast/Brunch
Luncheon
Workshop
Other
Date/Time of Event
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location of Event
Theme
Requested Service for Keisha
Panelist
Speaker
Allotted Speaking Time
Are there other invited guests?
Yes
No
If yes, please list other guests
Venue Seating Capacity
Expected Attendance
Honorarium/Compensation Information
An honorarium of $2,500 is reserved for Keisha. A deposit of $1,250 is required immediately upon our team's approval of your request in order to secure the date. The balance must be paid upon Keisha's arrival to the event. Thank you!
Extra Notes:
Submit
Should be Empty: