Speaking Request Information

To enable Ms. Lord to best accomodate your request to speak at your event, to your group or company,
please answer the following questions. If required information is not yet known, simply fil-in "TBD"
Note: fuller submissions and flexibility increase our ability to meet your request):
 

1. Contact Information Your Name: Your Title: Email: Company/Organization:   Organization Purpose: Website: Address: City: State: Zip: Office Phone: Alternate Phone:   3. Speaker Considerations & Requirements Travel (airfare & hotel)   Please Select Yes No Nearest Major Airport To Event Location:   Other Considerations:   Honararium:   Please Select $2,000 to $3,500 $3,500 to $5,000 $5,000 to $7,500 $7,000 to $10,000 $10,000 to $15,000 $15,000 to $25,000 $25,000 to $50,000 $50,000 to $75,000 $100,000 & Up To be determined Time frame in which decision is needed from Ms. Lord:   Please Select 30 days or more 14 to 30 days 14 days or less Materials required from Ms. Lord: Deadline for materials from Ms. Lord Please Select 30 days or more 14 to 30 days 14 days or less How did you hear about Ms. Lord?				2. Event Information Name of Event: Type of Event Event Frequency: Preferred Date(s): Alternate Date(s): Event Time(s): Group Size: Audience: Event Address: Event State: Zip: Location Phone: Location Fax:   4. Speaker Presentation Information No. of speakers appearing:   Time Allotted to Ms. Lord   Please Select Under 30 minutes 30 to 60 minutes 60 to 90 minutes 1-1/2 to 3 hours 3 to 6 hours More than one day Preferred Topic:   Secondary Topic:   If there will be multiple speakers at the event, please describe the topics that will be covered briefly: (maximum response 255 characters)