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Field with * is required.
 
Name of Speaker(s) Requested *:
 
Name of Host Organization *
 
Address *:
 
Contact info:(tel, fax, email) *:   
 
Primary Contact Person and Position *:
 
Name of Event *:
 
Purpose/Goal *:  
 
Scheduled time of event date(s) *:
 
Length of time speaker is expected to present *
 
Number of people expected *:
 
Describe audience(age, range, sex special needs) *:
 
Location of Event *:
 
 
How will the event be advertised*?
Is this an annual event*?   
 
 
Is this a one time event*?   
Is this the first time for this event*?   
 
Do you need additional information from the speaker(s)*?   
 
If you have any additional information please enter it here.
 
   

We require that all sessions be recorded for DVD and/or CD.

A limited number of private counseling sessions/consultations may be arranged by appointment before/after the engagement. Kindly advise us of any interest in taking advantage of this offer as soon as possible.


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