Name of Organization(required)

Event Title and Location (City / State):(required)

Requested Speaking Date (s):(required)

Target Audience:(required)

Expected Attendance(required)

Purpose of Event:(required)

Will Deborah be able to sell her books, tapes, CDs, and products at your event? *(required) Yes No

Event Budget for Speaker:

Names of Other Special Guests:

Organization phone number(required)

Organization Website

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

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:(required)

Your name(required)

What is your role with planning the event? Decision Maker, Event Planner, Committee Member,Interested Party(required) Decision Maker

Event Planner

Committee Member

Interested Party

Your phone number(required)

Your e-mail address:(required)

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