Speaker Request Form

What's the official name of your group or organization.
What does your organization do?
If you have a fixed date in mind, please let me know. Otherwise offer a range of suggestions.
Please describe a bit about how you would like the event to unfold. How many minutes would I speak? Would I be on a panel? Would there be questions? Would you like me to stay for several days and work with small groups?
How can I get in touch with you?
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