Speaking Request

Name*

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Email*

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Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Website of Host Organization

Name Of Event*

Location*

Event Date*

Please Give a Brief Description of Your Event*

Approx # Of Attendees*

Who is the Target Audience?*

Desired Length of Speech / Panel Time*

Is there a particular topic or text you would like to address?*

Additional speakers at the event:*

Other Details

Are there any other additional requests?*

Will you be covering travel expenses (i.e., airfare, lodging, meals, and rental car)*

Are you able to cover travel expenses for an assistant?*

Will you provide Carmen with a quality, digital audio or video recording to use at her discretion?*

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