Speaker Engagement Please take a moment to answer all required information and return the form via email or mail to our office. I. ORGANIZATION Business/Organization Name: * Business Phone: * Primary Point of Contact: * Contact Number: * E-mail Address: * Type of Organization: * ...Select an optionCorporationNon-profitOther Budget: * ...Select an option< 1k1k-5k5k-10k10k-15k15k-25k> 25k II. EVENT Event Date/Time: Venue: Address: Phone Number: Event Title/Theme: Topic would you like me to speak about: Leave a Legacy Before the End of Your Life Social Media 101 Custom Custom Topic: Sensitive issues that should be avoided: Available audio / visual resources: Are you able to pay for all expenses? Yes No III. AUDIENCE Total number attending the event: Who will be in your audience? Any information you can share about the audience that might be helpful?