Speaker Application Form – Applicants Must Be 18 Years of Age or Older

First Name:

Last Name:

Email:

Phone:

City:

State:

Address:

Zip Code:

On a scale of 1-10, rate your speaking ability:

List your 1st speaking topic:

List your 2nd speaking topic:

List your 3rd speaking topic:

Are you willing to travel for speaking engagements?

What is the largest amount you have received for one speaking engagement?

What are some specific goals you have for your speaking career? Also, can you post a video link of you speaking?