Speaker Request Form

Organization Name *

What's the official name of your group or organization.

Web Site

If your group has a web site, please list it.

Organization Description *

What does your organization do?

Dates *

If you have a fixed date in mind, please let me know. Otherwise offer a range of suggestions.

Structure of Event *

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?

Contact Information *

How can I get in touch with you?

Best Email *

What is the best email for contacting you? This software will also use it to create a receipt so you know the request was received.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Math question * 11 + 3 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

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Speaker Request Form

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