1-310-671-7136 • info@blackspeakersonline.com
 


Online Event Form

 
INSTRUCTIONS: After filling out this form online, PRINT a copy for your records, then either click the SUBMIT button to SECURELY email it to us, or fax it to 323-734-7010, or physically mail it to Speakers Etcetera, 1968 W. Adams Blvd., Suite 208, Los Angeles, CA 90018.
 
 
 
Please tell us about the Event or Group needing the Speaker
Organization Name:  
Product, Service or
Mission of Organization: 
Describe the Event: 
EVENT Date: 
EVENT Time: 
AUDIENCE Type: 
AUDIENCE Size: 
Location of Event: 
 
 
Tell us about your Speaker Requirements
 
Type of Presentation   Keynote
Seminar		 Emcee
Other: 
   
 Length of Presentation   Under 30 minutes
30 - 45 minutes
45 - 60 minutes
60 - 90 minutes		 90 minutes - 2 hours
1/2 day
Full day
Other: 
       
Budget Range   Free
Under $1500
$1500 - $3000
$3000 - $5000
$5000 - $7500
$7500 - $10,000
Over $10,000		 If you have a fixed
budget amount
indicate here
$
 
Other Expenses   Most speakers will also require travel, hotel, meals, etc. Do you have budget for these expenses?
  Yes No
 
Comment re: budget
 
 
What Topic(s)?
 
Identify the Topics which most meet your need(s).
 
Topic(s): 

Topic(s): 

Topic(s): 

Topic(s): 

 
 
What Speaker(s)?
Speaker(s): 

Speaker(s): 

Speaker(s): 

 
 
Comments,
questions
 
 
Contact Information * = Required
*Name: 
*Email Address: 
Company Web Address: 
Voice Phone: 
Fax Number: 
Address: 
City/State/Zip: 
 



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Phone: 310 671-7136 1968 W. Adams Blvd., Suite 208, Los Angeles, CA 90018 ©2006 Speakers Etcetera. All rights reserved.