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Your Name
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ORG/Association
Direct Email Address
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Address of Event
*
Cell Phone Number
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Speaking Type
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General Talk
Presentation
Keynote
Workshop
Master of Ceremony
Panel
Other
ORG/association Website Link
*
Date of Event
*
Event City/Country
*
Who is the target audience? raw public, bridge starts, recoveries, WISE
*
What is your ideal scene outcome for the event?
*
What is your budget if speaking event?
Expected # of attendees
*
Do you cover travel expenses?
Yes
No
Limited
Other
Do you cover accommodations?
Yes
No
Limited
Other
If flight required - Do you cover ground transportation - to/from airport? Or have a pick up service?
Yes
No
Limited
Other
Do you pay a speaker fee or stipend?
Yes
No
Limited
Other
Tell me anything else you would like me to know?
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