Speaker Request Form

1

Name* This field is required.

First Name

Last Name

2

What is your email?* This field is required.

3

Company/Organization Name* This field is required.

4

What is your best contact number?* This field is required.

Area Code

Phone Number

5

Name of Event* This field is required.

6

Date of Event* This field is required.If date is not finalized, please put a tentative date.

7

Address/Location* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

8

Time of Event* This field is required.(Ex: 12pm - 3pm)

9

Type of Event* This field is required.

10

Expected Number of Attendees* This field is required.

11

What is your speaker budget?* This field is required.Please include exact dollar amount or range

13

How long will you need Dr. LaQuista to speak?* This field is required.

14

Presentation/Speech Topic Preferred?* This field is required.Ex: Mental Health, Military, Trauma

15

Will Dr. LaQuista be allowed to promote any of her products/services?* This field is required.

Yes

No

Let’s Discuss It!

16

Will travel accommodations be provided? Please keep in mind, Dr. LaQuista is located in Atlanta, GA.* This field is required.

Yes

No

N/A

17

Any additional information you would like Dr. LaQuista to know or consider?

18

Thank you for submission. Dr. Erinna will be in touch with you shortly.