First & Last Name:

Email:

Your Company/Organization:

Phone Number:

STATUS OF COMPANY/ORGANIZATION:*
For ProfitNon-Profit

Name of Event:

Date of Event:
Time of Event:

Address/Location:*

TYPE OF EVENT* (EX: BRUNCH, WORKSHOP, CONFERENCE)

THIS EVENT WILL BE :*
In-PersonVirtual

EXPECTED NUMBER OF ATTENDEES:

PLEASE LIST ANY EVENT SPONSORS:

MEDIA: WILL MEDIA BE INVITED? IF SO, PLEASE PROVIDE THE MEDIA LIST.
YesNo

COST OF ATTENDANCE (PLEASE INCLUDE MEMBER AND NON-MEMBER PRICE, IF APPLICABLE):

WHAT IS YOUR SPEAKER BUDGET? (INCLUDE EXACT $ AMOUNT OR RANGE):

HOW WOULD YOU LIKE FOR MARJORIE TO CONTRIBUTE TO YOUR EVENT?: Keynote SpeakerWorkshop FacilitatorTrainerPanelistHost/MCOther

HOW LONG WILL YOU NEED MARJORIE TO SPEAK?:

PRESENTATION/SPEECH TOPIC PREFERRED
(EX: MENTAL HEALTH, HEALTHY RELATIONSHIPS):

WILL THIS SPEECH BE FOLLOWED BY A Q&A SESSION?
YesNo

WILL MARJORIE BE ALLOWED TO PROMOTE ANY OF HER PRODUCTS/SERVICES?
YesNoLet's Discuss It

WILL TRAVEL ACCOMMODATIONS BE NEEDED?* PLEASE KEEP IN MIND MARJORIE IS LOCATED IN HAITI & WASHINGTON, DC.
YesNo

DEADLINE FOR ACCEPTANCE (PLEASE PROVIDE EXACT DATE)

HOW DID YOU HEAR ABOUT MARJORIE?
ANY ADDITIONAL INFORMATION YOU WOULD LIKE FOR MARJORIE TO KNOW OR CONSIDER?

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