Speaker Registration Form

I am a:
Speaker    Author     Athlete    Entertainer   
Other
Contact Information:
Name:
Company:
Address:
Address:
City:
State:
Zip:
Country:
Work Phone:
Fax:
E-Mail Address:
Web URL:
Booking Contact:
Name:
Phone:
Video: Submissions without video will not be considered
I will mail a DVD or CD 
Link to online video files

Please mail DVD or CD to:

New Speakers
International Speakers Bureau
1401 Elm Street, 41st Floor
Dallas, TX 75202
 
Fee Information:
Current Fee:  Gross    Net:
Keynote Fee:   
Half Day:   
Full Day:   
Is your fee different for in-town or non-profit organizations: Yes No

If Yes, please Explain:

Number of presentations you have given in the past year:

Background:

Briefly describe your background including any awards or other recognitions:
Programs/Presentations:

Please list the titles of your most popular speeches/presentations:

Select your most popular topic areas:

1: 2:
3: 4:
5:    
Expenses:

Airfare Requirements:
Coach    Business Class:    First Class   
Other:   

Home Departure Airport:     
No. of Accompanying Passengers:

Other Misc. Expenses:

Ground Transportation   Lodging   Meals  Per Diem  
Shipping of Material   Other

Audio/ Visual Requirements:

Lavaliere Mic.   Handheld Mic.   Overhead Projector  
Screen LCD Panel  VCR/ TV 
Podium  Whiteboard   Audio Cassette Player  
Slide Projector    Easel/ Tablet   Other

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