Speaking Request Form

Please complete this form with details regarding your event.

We will contact you within 24-48 hours to discuss your event needs.

Thank you!

First Name(required)

Last Name (required)

Company/Organization (required)

Email (required)

Phone (required)

Website

Billing Address (including Street, City, State, Zip Code

Event Details

Proposed Event Date

Proposed Event Time

Location of Presentation (address, room number, etc.)

Proposed Length of Keisha's Presentation

Purpose of Event

Is there a theme or slogan for this event? If so, what is it?

What type of presentation are you interest in?
WorkshopKeynote SpeechPanel DiscussionOther

Estimated Number of Participants

Age range & demographics of the participants

Your budget for this presentation
$500-$1000$1001-$1500$1501-$2000$2001-$3000$3001+

Is audio/visual equipment available?
YesNo

Will you allow Keisha to have a product/information table at the event?
YesNo

If requesting a presentation outside of Dallas, TX, is travel and lodging included? Will ground transportation be provided? What is the closest airport?

Brief description of your needs/topics you would like addressed?

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