Speaker Request Form

Day-of contact person's name

First Name

Last Name

Email Address

Phone

(###)

###

####

Expected Crowd Size

Click on the drop down box to see more options.

Audience Makeup

Click on the drop down tab to see more options.

Event Description

Please give a brief overview of event AND speaker responsibilities and expecations.

What would you like Green to speak about? Click the drop down to to see additional speaking topics.

**Details: What EXACTLY would you like the talk to be about? What would you like the speech to accomplish? What would you consider a successful talk? What would you like your team to takeaway?

Please answer all (4) four questions and be as detailed as possible to ensure clear communication.

If you would like Earlina to speak on a panel OR variety of topics, list that below.

Website

Event or organization's website.

http://

Date

What day is the event?

YYYY

Time

What time should speaker arrive?

Hour

Minute

Second

End Time

What time will the event end?

Hour

Minute

Second

Address

Where will event take place?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PAYMENT: Speaker does charge for services rendered. Fee is based on audience size and event location. Once form is submitted, please give us 3-7 days to review and present a proposal.

Is there a budget for event?

Yes

Event Budget?

Other form of payment

Yes

Please explain. If you need additional payments options, such as a payment plan, state that here.

IMPORTANT: YOU WILL BE DIRECTED TO A "THANK YOU" MESSAGE AFTER HITTING THE "SUBMIT" BUTTON. IF YOU ARE NOT, PLEASE HIT THE "SUBMIT" BUTTON AGAIN.

If you have additional questions or comments regarding this form, email earlina.green@gmail.com.