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Request Sam to speak
Name
*
First Name
Last Name
Email Address
*
Phone Number *
Subject
*
Message
*
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Are these dates flexible?
Yes
No
What organisation is sponsoring the event?
What is your role with the organization?
Event website url:
Where is the event located?
What is the name of the event?
What is the vision and purpose of the event?
If any, who are the other speakers?
Is the event open to the general public or by invitation only?
General public
Invitation only
Will there be a charge for admission to the event?
Yes
No
Will the event be recorded and/or filmed?
Yes
No
What is your target audience?
What is the expected audience size?
How many times would you need Sam to speak?
How long would you need Sam to speak for each message?
What specific topics are you requesting he cover?
Do you agree that your organization will cover all travel expenses plus an associate?
Yes
No
Honorarium amount:
When do you need a formal commitment from Sam?
MM
DD
YYYY
How did you hear about Sam?
Additional comments / questions:
Thank you!
CONTACT SAM
Name
*
First Name
Last Name
Email
*
Subject
*
Message
*
Thank you!
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