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First Name
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Last Name
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Email
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Number
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Company/Organization
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Name of workshop, seminar, or speaking event
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Date & Time of event
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Is meeting date fixed or tentative?
Fixed
Tentative
Address/Location of the event
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Will travel accommodations be needed? Please be advised that Dr. Geneva is in Detroit, MI
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Yes
No
N/A
Specific content to be covered?
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Event sponsor(s)
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Expected number of attendees
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Will Media Be Invited? If so, Please Provide the Media List.
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What is your speakers budget? (Include exact $ amount or range)
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How long will you need Dr. Geneva to speak?
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How would you like for Dr. Geneva to contribute to your event?
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Keynote Speaker
Workshop Facilitator
Trainer
Panelist
Host/MC
Other
Will this speech be followed by a Q&A session?
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Yes
No
Will Dr. Geneva be allowed to promote her products/services?
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Yes
No
Let’s Discuss
Deadline for acceptance (Please provide exact date)
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Any additional information you would like for Dr. Geneva to know or consider?
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