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:

5 + 0 = ?Please prove that you are human by solving the equation *