Speaking Request Form

Dr. Natasha generally books speaking engagements at least four months out. If you are interested in having Dr. Natasha speak, please complete the below request form and someone will follow up with you within ten business days. Please be mindful that speaking request expenses include the speaker’s honorarium (fee), covers all travel expenses (including transportation, lodging, per diem for meals) for speaker and her traveling companion, and book sales to sell or gift at the event.

Prefix

Name

First Name

Last Name

Title/Position/Organization

Primary Phone Number

(###)

###

####

Secondary Phone Number

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Event Name

Event Start Date

YYYY

Event End Date

YYYY

Event Location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Venue Type

Type of Event

Please describe the mission, purpose, and history of the event:

Targeted Audience

Anticipated Attendance (insert number)

Please help Dr. Natasha better serve you by describing the diversity of the audience.

What type of sessions would you like Dr. Natasha to participate in?

Please check all that apply.

Keynote Speaker

Workshop Presenter/Facilitator

Pre-conference Track

Leadership Training

Panel Participation: Speaker or Moderator

Interview

Is there a specific topic you have in mind for Dr. Natasha to share?

How will you publicize this event (Please include social media, website, partnership information)

How did you hear about Dr. Natasha?

What honorarium are you prepared to offer Dr. Natasha? (Note: Please provide information in U.S. Dollar amounts.)

Is there anything else we need to consider concerning the request, event, vision, or audience?