Full Name *

Email *

Phone *

Name of upcoming event *

Date of event *

What type of event *

Virtual

In Person (Live)

Estimated number of attendees *

Provide a brief description of the event and its mission *

What is your budget for hiring a keynote or headline speaker for your event? *

Will travel and hotel accommodations be covered? (just type na if virtual) *

Will Dr. Alicia have the opportunity to sell her products or services? *

Why do you think Dr. Alicia will be a great fit for your event? *

Please provide the names of other people of influence speaking at this event *

Anything else you want us to know? *

Proposed time to connect & speak about the event *

Attach flyer or promotion information