Speaking Request Please complete the form below to request Dr. Andrea to speak: Name of Workshop, Seminar, or Speaking Event*Sponsoring Group*Name of contact person* First Last Phone Number*Email* Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Meeting SpecificsMeeting Location*Is meeting date fixed or tentative?*Specific content to be covered?*Specific meeting times*Actual speaking time during each meeting*Are there other speakers? If so, who?*Number of attendees expected*Median age of attendees*What is the theme for your event?*Honorarium (please write a specific U.S. dollar amount)*The honorarium check should be made out to Pam PerryWill honorarium be given in advance?*YesNoThe final day of meetings?Special arrangements needed?Overnight AccommodationsHotel NameHotel Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Hotel Phone NumberLogisticsCan you supply (check all that apply) P.A. System Large Screen TV or Projector DVD Player Powerpoint/LCD Projector Cordless or Lapel Microphone 8' Table Photo Copies Markers Pad & Easel Blackboard w/Chalk & Eraser Whiteboard w/ Markers & Eraser Table for Speaker Products Any Special needs your organization may have when it comes to logisticsExpenses (Meetings less than 200 miles)What is mileage from speaker's hometown?Will auto travel of 33 cents per mile be covered?YesNoExpenses (Meetings more than 200 miles)(Air travel arrangements will be made by Dr. Andrea Blake unless agreed otherwise)Will air travel be covered in advance?What is the length of travel time from airport to meeting place?Who will transport to/from airport?Please enter name abovePlease provide the work and home phone numbers of the person above who will be transportingPerson Completing FormName of person completing this form* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone numberEmail* Position/TitleNote:After we have sent you a letter confirming all arrangements, a cancellation fee of 25% of the honorarium will be assessed on the party who cancels the engagement. The canceling party will also be responsible for any non-refundable airfare/travel costs or misc. expenses.