Request for Motivational Speaking Engagement

Please complete this information in its entirety.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

Name: *
Name:
Work Phone: *
Work Phone:
Mobile Phone:
Mobile Phone:
Address *
Address
Who is hosting the event?
http://
Event Date: *
Event Date:
Time: *
Time:
Type of Event: *
Will the event be video taped? *
If yes, we reserve some rights to duplicate.
Will the event be audio taped? *
If yes, we reserve some rights to duplicate.
If applicable, include the event topics, scripture(s), etc.
Is there a Special Topic you want Carmen to address? *
Is this a ticketed event? *
$
**Upon execution of the contract, a 50% deposit will be required within 7 business days**
$
Please include any additional information/comments to assist us with your request.

Please consider the following logistics request when submitting this form:

  1. Accommodations: Two (2) rooms with queen size beds at a four start hotel - MUST BE NON-SMOKING
  2. Travel:  Two (2) coach tickets (non-stop flights) All baggage fees must be paid prior to departure. Ground transportation.  Driver must be available at all times).  All baggage fees must be paid prior to departure.
  3. Product Table