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 Δ Share this:TwitterFacebookLike this:Like Loading...