JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Speaking Engagement Request
To request that
Professor Sam Museus
consider a speaking engagement, please fill out the following information and allow 1-2 weeks for a reply. Please direct any questions you have to NITESurveys@gmail.com. Thank you.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Position/Title:
*
Your answer
Organization:
*
Your answer
What type of speaking arrangement would you like to book?
*
Keynote address
Guest lecture, talk, or presentation
Professional development workshop or training
Other:
What is the name of the organization hosting the event?
*
Your answer
Please share a brief description of the event yo
u are planning and the primary audience?
*
Your answer
If you want the guest speaker to focus on a specific topic or achieving specific outcomes, please share a brief description. Otherwise, please write "open."
*
Your answer
How many attendees are expected at the event?
*
1-20
21-50
51-100
101-500
501-1,000
Over 1,000
If you have a planned date for the event, please share the day you hope for it to take place.
MM
/
DD
/
YYYY
If you have a predetermined budget for booking a speaker and are comfortable sharing, please select one of the following. Otherwise, please select "unsure."
*
Under $5,000
$5,001-$10,000
$10,001-15,000
Over $15,000
Unsure
Please provide any other relevant information that you wish to share here:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
