Name/Address of Organization (required) *
E-Mail *
Phone Number *
Subject
Expected Attendance:
Event Budget for Speaker:
Organization Phone Number:
Organization Website:
Purpose of Event:
Describe exactly what you are requesting of Deborah (keynote message, seminar/workshop leader (# of presentations), moderator, etc.):
Please give us a brief history of this event, i.e., previous speakers, past attendance, annual (if so, how many years): Background information on your organization:
What is your role with planning the event? Decision Maker, Event Planner, Committee Member,Interested Party:
1 + 3 = ?Please prove that you are human by solving the equation *