Speaker Request Form Name * First Name Last Name Email * Company/Organization Phone (###) ### #### Status of Company/Organization For profit Nonprofit Name of event Date & time of event Address/Location Type of Event (brunch, conference, workshop) This event will be In person Virtual Expected number of attendees Please list any event sponsors Media: Will media be invited? Please provide the media list Cost of attendance (Please include member & nonmember price, if applicable) What is your speaker budget? (Include exact amount or range) How would you like Candice to contribute to your event? Keynote Speaker Workshop Facilitator Trainer Panelist Host/MC Other How long will you need Candice to speak? How long will you need Candice to speak? Will this speech be followed by a Q&A session? Yes No Will Candice Be Allowed To Promote Any Of Her Products/Services?* * Yes No Let’s Discuss it Will Travel Accommodations Be Needed?* Please Keep In Mind Candice Is Located In New Jersey. Yes No N/A Deadline for acceptance (Please provide exact date) MM DD YYYY How did you hear about Candice? Any additional information you would like for Candice to know or consider? Thank you!
