Name

Just your legal first and last name.

First Name

Last Name

Preferred Full Name

Please write out your name as you would like it to officially appear in our marketing materials, web, Youtube, etc. Example: "Brandon Keith Weber, PhD."

Email Address

This should be the best email to reach you at. It should not be an assistant's or agent's email.

Email to CC our communications to

If you have someone that you would like for us to cc, please input here.

Mobile Number

Mobile number to reach you at.

Country

(###)

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Preferred Number

If there is a number that you prefer us to reach you at, we will use this (but we will still need your mobile number above).

Country

(###)

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Skype "handle"

We will use either skype or Google Hangout at some point with you.

Google Hangout ID (usually your Google email)

We will use either skype or Google Hangout at some point with you.

Twitter Handle

Only if you want to share it.

Facebook Page

Only if you want to share.

Working BIO (200-250 words)

This is the bio that we will be using for marketing, program, and eventually your video bio, etc. This will help our viewer understand why they should listen to you. It's also good to tell us something about your passions, rather than just a laundry list of accomplishments. Don't worry, there will be time to adjust and refine.

What Motivates You?

Why do you do what you do? Why do you want to share your idea? This will help our team to understand you and better assist you in shaping your talk.

Idea Worth Spreading

In three sentences or less, please tell us the idea that you would like to share from our stage. Don't worry, there will be time to change or refine. We recommend a more focused message over a broad one for the sake of both time and impact.

Question your talk attempts to answer

It often helps to think about your talk as an answer to a question or a problem. Please pose this in the form of a question.

Working Title of Talk

This is just a working title. There will be time to change.

Would you like to request additional passes to the event?

If you plan on bringing a guest(s), please let us know.

If yes, how many?

We only guarantee 1 guest pass to the event, but we will try to accommodate more, if needed.

Questions

Any Questions or Concerns that you might have that our team might help to address?

speaker information