Speaker Request

First & Last Name*

Email*

Company/Organization*

Status of Company/Organization*

Name of Event*

Date & Time of Event*

This event will be *

Address*

Expected Number of Attendees*

Cost of Attendance (Please include member and non-member price, if applicable) *

Please list any event sponsors:

MEDIA: Will media be invited? If so, please provide the media list.

What is your speaker budget? * (Include exact $ amount or range)

How would you like for Nicole to contribute to your event? *

Presentation/Speech Topic Preferred* (Ex: Classroom Management, Workplace Skills, JOY etc. ))

Will this speech be followed by a Q&A session? *

Will Nicole be allowed to promote any of her products/services?*