Company/Association/Organization): 

(Please provide information about company, association or organization.)

Company/Event Website:

Contact’s Name & Title:   

What is your role with planning the event: 

Contact’s Address/City/State/Zip:    

Contact’s Email

Contact’s Phone

Event location -  (City | State | Venue)

What is the Date of Event?

What Date & Time Would Dr. Stephanie Speak?

Purpose of meeting/event

Demographic and Profile of Group(s) to be spoken to:    

What is your budget?  

Is travel/lodging included for the speaker PLUS one assistant?  What is the closest airport?  Will ground transportation and meals be provided?

(Dr. Stephanie travels from Atlanta, GA)    

Will Dr. Stephanie be allowed to sell her products? Would you like for Dr. Stephanie to do a book signing at the event?  How many people will attend?  Are you interested in pre-ordering books?

Will the event be recorded?  Will the recordings be available for purchase?

How long would the presentation last?

Additional Comments: