Speaker Request Form

Thank you for your interest in having J.R. speak at your upcoming event. Please fill out the form below. We will reply to your request within 1 week.

Contact Person Name

First Name

Last Name

Contact Email

Contact Phone Number

(###)

###

####

Event Date

MM

DD

YYYY

Event Location / Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Description of Event

Who is the audience (i.e. demographic, personality, amount of people expected at the event, etc.)?

Desired Topic(s):

Time speaker is expected to arrive at the event

Hour

Minute

Second

Approximate length of time speaker should present

Desired attire of speaker

Anticipated honorarium

Kairos Partnerships 2021 rates for speaking (available upon request).

Any additional information that might be helpful for the speaker to know ahead of time

Speaker Request Form

Speaker Request Form

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