Name of Organization:

Event Title and Location (City / State):

Requested Speaking Date (s):

Target Audience:

Expected Attendance:

Purpose of Event:

Event Budget for Speaker:

Names of Other Special Guests:

Describe exactly what you are requesting of Deborah (keynote message, seminar/workshop leader (# of presentations), moderator, etc.):

Please give us a brief history of this event, i.e., previous speakers, past attendance, annual (if so, how many years):

Background information on your organization:

Organization phone number:

Organization website:

Your name

What is your role with planning the event?

Your e-mail address:

Your phone number:

Will Deborah be able to sell her books, tapes, CDs, and products at your event?

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