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First Name*

Last Name*

Email*

Company/Organization Name*

Phone*

Type of Organization*

Event Name*

Event Date and Time*

Month

Day

Year

Time

:HoursMinutes

What is the exact time for Dr. PJ's anticipated arrival?*

Time

:HoursMinutes

Event Format*

Event Location/Address*

Expected Number of Attendees*

What are the primary characteristics of the expected/targeted audience?*

Type of Event*

Conference, Workshop, Brunch, etc.

Will Media Be There? If so, please provide Media list.*

Cost of Attendance (provide member & non-member price, if applicable)*

What is your speaker budget? (include exact cost and/or range)

In what capacity would you like Dr. PJ to participate?*

Keynote Speaker

Workshop Facilitator

Trainer

Panelist

Moderator/Interviewer/Host

Appearance

Other

How long would you like Dr. PJ to speak?*

Desired Topic*

Please indicate what will be available for the speaking request.*

Podium

Microphone

Projector & Screen

Table

Chair/Stool

Other

Will Dr. PJ be allowed to promote her books and/or services?*

Will travel arrangements be necessary? Dr. PJ is based out of Houston, TX*

Deadline for Acceptance*

Month

Day

Year

Time

:HoursMinutes

Provide a link to the event page and/or any promotional site

Any additional information you'd like to share?*

DEBORAH DAVIS

We Mean Business Chairperson

"Your presentation about Maintaining Relevance resonated with our participants and was well received. Several participants stated that your session provided them with valuable information that they could immediately implement."

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