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SPEAKER REQUEST FORM
For more information on Fees, Topics and Availability or if you'd like to Sponsor a Speaking/Media tour please provide more information about your event/meeting below.
Today's Date:
Your Name:
Phone:
Fax:
Email Address:
Name of Organization:
Date of Event/Meeting:
Type of Event/Meeting
Purpose of Event/Meeting
Please explain more about event/meeting:
What is your budget for this event?
Organization Address:
City:
State:
Zip:
Phone:
eMail:
Event/Meeting Contact Name:
Program theme, you must check one: ACT as if!
Eating Disorder
Show Business 101
Other Topic
How long is the scheduled event/meeting? (hours)
May Barbara bring back-of-the room products? (DVD's, books, etc) Yes
No
If yes to the above question, will a table be provided? Yes
No
Will a lectern or microphone be provided? Yes
No
Will access/connections for a computer be avialable? (electrical, Internet access, projector setup) Yes
No
If no access/connections for a computer what audio visual equipment is available?
Are printing/photo copy services provided or nearby? Yes
No
Number of Attendees:
Average Age:
How will the organization publicize the event/meeting?
Does the organization have a newsletter? Yes
No
Check this box if meeting location is different that above:
Event/Meeting Location Address:
Additional info you'd like us to know about the event/meeting:

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