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Speaking Intake Form
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Name
*
First
Last
Email
*
Phone
*
Organization hosting / sponsoring the event
*
Organization's website
What is your role for this event?
*
In-house employee / event-coordinator
Contracted or consulting event-planner
Speaker's bureau or agency
Other
If other, what is your role for this event?
*
Event start date
*
Month
Day
Year
Location of event
*
Date Julie will speak
*
Month
Day
Year
Event format
*
Virtual, live event
Virtual, pre-recorded event
Live, in-person event
Recorded, in-studio
Other
If other, what is the event format?
*
Event venue address
*
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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Northern Mariana Islands
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Puerto Rico
Rhode Island
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Speaking role
*
Keynote (45 mins)
Panel member
Panel moderator
Breakout session (45 mins)
Executive summit (5-20 attendees, 2 hours to half day)
Emcee / host for 1-3 hour event
Emcee / host for full-day event
Emcee / host for 2+ days
Other
If other, what is the speaking role?
*
Anticipated attendance or registration
*
Less than 50
50-150
150-300
300-500
More than 500
Audience description
*
Topic / theme for the event
*
Speaker budget
*
$6,500-$10,000
$10,000-$15,000
$15,000-$20,000
More than $20,000
Other important details we should know
How did you hear about Julie Brown?
*
Phone
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