| First Name: |
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| Last Name: |
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| Address: |
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| Telephone: |
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Contact Phone :
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Alt Contact Phone:
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| Email: |
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| Password: |
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| Which method do you prefer to be contacted by? |
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Mail
Phone
Email |
Employer:
(Optional) |
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Please list in order the different topics or subject areas you speak about and briefly explain your area of expertise on the topic and in what you specifically talk about as a part of that particular subject area. Also, please indicate approximately how long each speech is in duration. |
| 1. |
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Topic |
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| 2. |
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Topic |
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| 3. |
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Topic |
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| Please Provide a short bio of yourself. Please include education, community background, level of experience and other pertinence information. |
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Yes
No
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Are you available to speak at early morning Breakfasts (6 a.m. - 8 a.m.)? |
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Yes
No |
Are you available to speak at luncheons? |
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Yes
No |
Are you available to speak during normal business hour? |
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Yes
No |
If not what hours are available to you? |
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Yes
No |
Are weekends better? |
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Yes
No |
Do you require a fee, if so how much? |
| Do you require any equipment for your presentation (i.e. projection screen, projector, laptops, etc.)? |
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laptop
projector
projector_screen
tables
power_source
other
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| Please list groups that you have spoken to in the past and what topic or subject. |
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| Is there any other information that you feel would be useful to other agencies looking for a speaker that is not included in this form, if so, please fill in below. |
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