Speaker Request Form | Nicole Tetreault, PhD

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NAME

EMAIL

PHONE

LOCATION OF EVENT

ORGANIZATION

PREFERRED DATE

ALTERNATE DATE

DESCRIPTION OF YOUR REQUEST

PROPOSED SPEAKER FEE

WILL YOU COVER TRAVEL EXPENSES?

Airfare

Hotel

Ground/Mileage

Meals

Unable to cover expenses (or no travel is required)

IS THE EVENT OPEN TO THE PUBLIC?

Yes, it is open and free to all.

No, this is a private event.

Yes, but registration is required.

Don't know or have not decided whether this event is open.

PLEASE ADD ANY ADDTIONAL INFORMATION HERE

Thanks for submitting!

Thanks for staying connected!

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