Name of organization/business: *

Contact Person First name: *

Contact Person Last name: *

Email *

Phone Number: *

Date or Dates of Event: *

Address of Event: *

City: *

State: *

Zip: *

Dress Attire: *
CasualFormalBusiness CasualSemi-formal

Website: *

Date Denice is requested to speak: *

Event theme or purpose: *

Time of event: *

Name of location event will be held: *

Address of event if different from organization/business: *

How much time will be allotted to speak: *

Will there be a reception/breakfast/lunch/ dinner during or following the event: *
YesNo

Brief Summary of what you would like Denice to accomplish at the event:*

Expected # of Attendees: *

Lapel Microphone (preferred)Headset MicrophoneHandheld MicrophoneCordless Handheld MicrophoneVideo Projection - for notes/clips

Honorarium Budget for Denice:*

Comments:

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