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Jasmen Rogers Speaker Request Form
If you're interested in having Jasmen speak during your keynote, at your press conference, or on your panel, fill out this form completely and we’ll get back to you as soon as possible.
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* Indicates required question
Organization/Company Name
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Your answer
Your Name
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Your answer
Point of Contact Name (if different than above)
Your answer
Contact Email
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Your answer
Contact Phone
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Your answer
Description of Event
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Please include name, purpose of event, and any other relevant information that will help us prepare.
Your answer
Event Location (venue name, address)
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Your answer
Date of the Event
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Event Start Time
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Time
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AM
PM
Event End Time
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Time
:
AM
PM
Speaker Call Time
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Time
:
AM
PM
Type of Engagement Requested
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Keynote
Panel Discussion
Press Conference
Interview
Other:
Requested Topic
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Your answer
Other Confirmed Speakers/Panelists
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Your answer
Expected Audience Size
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Your answer
Will this event be recorded/live streamed?
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Yes
No
Is There An Honorarium?
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Check all that apply.
Travel Per Diem
Travel Reimbursement
Honorarium Available
Expectation of Speaking Provided In-Kind
Other:
Required
Deadline to Confirm Attendance
*
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Any additional details?
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Your answer
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