Speaker Request Form

Thank you for your interest in having Dr. Eric Mason as a speaker for your event. Please fill out the form below, and a member of our team will follow up with you to discuss your request in more detail.

Contact Information

Full Name

Position

Organization Name

Email

Phone

Fax

Website

Event Information

Event Name

Event Date(s)

Event Time(s)

Event Format

Event Theme/ Purpose

Expected Attendance

Target Audience

Speaker Topic Request: (Please provide a brief description of the topics or message you would like Dr. Mason to speak on.)

Event Details

Duration of Speaking Session

Other Speakers/Panelists

Do you require a Q&A session?

Will there be media coverage?

Will session be recorded or live-streamed?

Accommodations

Travel Arrangements: (If applicable, please detail what travel accommodations will be provided, such as flight, hotel, transportation.)

Honorarium Offered: (If applicable, please include honorarium amount or range.)

Additional Information

Additional Notes or Requests: (Please provide any other details or requests that would be helpful for us to know.)

Consent

I understand that submission of this form does not guarantee that Dr. Mason will be able to participate in our event. I also acknowledge that further discussion will be needed to confirm the details and availability.