Speaking Request Form

Speaking Request Form

If you'd like to have me speak at your upcoming event, please take a moment to fill out this form. I look forward to connecting with you—thank you!
Contact Information
Name of Requester*

First NameLast Name
Requesting Organization*
Email*
example@example.com
Website*
Phone Number*
Please enter a valid phone number.
Are you the organizer or staff member of the upcoming event?*

OrganizerStaff Member
Event Details
What is the name of the event?*
When does the event take place?*

MonthDayYear
Will the event take place virtually or in person?*

In PersonVirtually
If the event is in person, please specify the location of the venue.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the theme or topic of the event?*
Do you need a copy of the MIK & Co. Ventures Logo or Personal Brand Logo?*

MIK & Co. VenturesPersonal BrandNo Logo Needed
Event Audience
Expected Audience Size*
Audience Demographics*

Aspiring EntrepreneursEarly Stage StartupsSmall Business Owners Looking to ScaleCorporate Executives and Business LeadersWomen Entrepreneurs or Women in BusinessEducational Institutions (Business Schools, Universities, Trade Schools, High School)Nonprofits and Social EnterprisesWorkshops and Masterclasses for Entrepreneurs
Logistics
Speaker Session Format*

KeynotePanel discussionWorkshopOther
Duration of Session*

Hour Minutes
Would you like a biography and photo of the speaker?*

YesNo
Equipment/AV Requirements*
Speaker Must Arrive*

MonthDayYear
Date
Speaker May Depart*

MonthDayYear
Date
Additional Information
What is your budget for the speaker?*
* In USD currency only please.
Are accommodations provided for (e.g., hotel, transportation, meals)?*

YesNoOther
If other, please describe below what is covered for accommodations.
Are there any addittional requests or comments?
Should be Empty:

Speaking Request Form

Contact Information

Event Details

Event Audience

Logistics

Additional Information