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Event/ Organization name
*
First name
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Last name
*
Email
*
Phone
Date of Speaking Engagement
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City / State of Event
*
Single choice
Seminar
Keynote
Panel Discussion
Workshop
Moderating
Hosting
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Duration Expected to Speak
10mins
30mins
60+ mins
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Expected Audience Size
10 - 20
20 - 50
50 - 100
100+
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Speach Topic
Audience Demographics
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Gender
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Age
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Why do you think I am a good fit for this speaking opportunity?
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What is the effect you want the talk to have on the audience?
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What is the biggest issue that needs to be addressed in the talk?
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Will there be a Q&A Session afterwards?
Yes
No
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Will I be able to set up a vendor booth to sell my products?
Yes
No
Please link any pertinent information
Feel Free to add anything else that you feel I should know.
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