Speaker Agent Application Form * 1. Provide your contact Information: First and Last name State/Province/Country Zip code Email Address Phone Number * 2. Please describe your current position and provide brief work history * 3. Check all that interest you Keynote Speaker Author/Writer Media Spokesperson Keynote Trainer/Workshops Fireside Chat (Q&A from audience) Presenter - emcee (MC- Master of Ceremonies) Other - Please elaborate * 4. List any recent publications/presentations you have done recently. Publications Presentations Other * 5. List a reference that has listened to one of your presentations Name or Company Name Email Phone Number * 6. Describe your area of expertise, your signature talk - the more information you can provide about your niche and ideal audience the easier it will be for us to book business for you. Please include website and link to video (promo reel) * 7. What price range would you say your speaking engagements are at currently? $1000 - $5000 $5000 - $10,000 $10,000 - $15,000 $15,000 - $25,000 $25,000 and up * 8. Last but not least, if we sign with you today, do you have a Press Kit and Highlight Reel ready to go? YES NO I would like your marketing team to create that for me * 9. How did you hear about Karie Millspaugh/our company and speaking opportunity? Completed - Thank you for time!