Speaker Submission Form

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1. Speaker’s Contact Information:

Name: *

Title:

Company:

Address 1: *

Address 2:

City & State: *

Zip Code: *

Telephone: *

Facsimile:

Mobile:

Email: *

2. Assistant’s Contact Information

Name:

Telephone:

Facsimile:

Email:

Should this person be copied on all correspondence?:

Yes

3. Event Type

Preferences:

If applicable, please list specific events you are interested in speaking at (if more than one, please list in order of preference).

4. Expertise

Area(s) of focus:

5. Presentation Format

Type of Speaker/Presentation Format Preferred :

(please check all that apply)

6. Presentation Description

Details:

Please outline relevant details that include topic details, goals and objectives, the audience level your presentation is geared towards, and specific tools you plan to use.

7. Additional Speakers

Speaker info:

If you have more than one speaker or co-presenter(s) in mind, please list name, title, company and contact information for each individual above.

Presentation history:

If the presentation has been delivered before, please provide date, location and the organization delivered to.

Speaker Bio:

Attach a one-two paragraph updated bio no longer than 150 words MAX.

Speaker Photo:

Attach a Digital Headshot with the following specs: minimum 3x3 inches, no less than 300 dpi, color and sent as a jpg or gif file.

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