Speakers Bureau Information Form

Demographic information.

First Name (*)

Please type your FIRST name.
Last Name (*)

Please type your LAST name.
Suffix

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Title

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Bio (300 Words)

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Accredited in Public Relations:

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PRSA member

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PRSA Chapter affiliation

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Address

Company

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Address

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Address 2

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City

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State (*)

Select a state.
Zip

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Phone

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Fax

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Mobile

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Web Address


E-mail (*)

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E-mail2

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Industry

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Type of Industry

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Topic Information

Topic 1

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Topic 2

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Topic 3

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Topic 4

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Topic 5

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Where have you spoken in the past year?

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How many presentations on the above topics have you delivered?:

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YouTube video illustrating your speaking style:

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Any audio/visual requirements:

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Speaker Fees

What are your speaker fees?

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What are your fees for travel expenses?

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What are your fees for lodging

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How should we contact you?