Jason Mirikitani – SPEAKER REQUEST FORM

Jason Mirikitani – SPEAKER REQUEST FORM

(Please fill out this form as completely as possible so we can serve you best.) Click SUBMIT at bottom.
Name of Organization
Contact Person
Address
Phone #(s) used most
FAX #
Email address
1) Date(s) & times Jason will speak
2) What is the main purpose of the event? i.e. What to you hope happens as a result of Jason speaking?
3) Type of audience (age, size, etc.)
4) Were you hoping Jason's message would have a certain focus?
5) Number of times Jason will speak
6) How long Jason will speak each time
7) Transportation arrangements?
8) Payment amount for Jason speaking (to be paid before Jason leaves)
NOTE: Air travel cost must be reimbursed prior to event, & other discussed items can be reimbursed post event.

Checks made out to Jason Mirikitani.
8b) Paid in what way? (e.g. contract, honorarium)
9) Jason's housing accommodations for the event
10) Appropriate speaker attire (dress code)
11) Please include any further details about the event that might help Jason serve you best (Special needs, etc.)
12) How did you hear about Jason?
Should be Empty: