Speaker/Consulting Request Form

E-mail Address: *
Your name? *
Date(s) of event? *
Type of conference? *
Schedule & duration of speaking times? (i.e. plenary session, workshops, etc.) *
Is Tony the main speaker? *	Yes No
Other speakers (if applicable)? *
Estimated number of attendees? *
Makeup of the attendees? (i.e. age range, urban pastors, lay leaders, church planters, ethnic diversity, etc.) *
Organization’s name & mailing address? *
Contact person, phone/email info? *
How do you know Tony? (i.e. Where and when did you meet? Who referred him?) *
Overall purpose of the event? *
Requested topic? *
Location and address of the event site? *
Location of nearest airport to event? *
Photograph and biography required? *	Yes No
Would you be willing to provide travel expenses to cover Tony and one guest? *	Yes No
What is the anticipated honorarium for this event? *
Other comments/questions?


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