Speaker Request Form

Complete the form below to request a speaking engagement with Andrea or Nate Scott.

First and Last Name(required)

Title and Organization(required)

Email(required)

Phone

Website

Please Describe Your Event(required)

Event Location (City, State, Country, etc)(required)

Preferred Date / Dates(required)

Why Do You Want Andrea or Nate to Participate?(required)

Expected Number of Attendees 0 – 20 20 – 50 50 – 100 100+

Attendee Composition (department/level of participants)(required)

Will This Event Be Open to the Public? Yes No

Estimated Budget for Speaking Engagement $2500 – $5000 $5000 – $10,000 $10,000 – $15,000 No Budget

What Do You Hope to Accomplish at This Event?

Indicate Specific Topics as of Interest

What Is Your Preferred Presentation Format? Keynote Address

60 – 90 Minute In-Person Interactive Engagement

60 – 90 Minute Virgual Interactive Engagement

2 – 4 Hour In-Person Workshop

Panel Moderation

Panel Participant

Something Different

Would You Like to Include a Q & A? Yes

No

Any Special Requests or Comments?

Submit

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