Dr. Perkins Speaking Request Form

Thank you for your interest in inviting Dr. Perkins to Speak
Please complete the form below:

    Contact Information

    Primary Contact Name*

    Primary Contact Number*

    Primary Contact Email*

    Primary Contact Position

    Your Organization

    Organization Name

    Type of Organization

    Organization Website

    Your Event

    Name of Event*

    Date of Event*

    Location of Event*

    Type of Event

    Theme/Purpose of Event*

    Proposed Topic for Speaker*

    Presentation Format (panel, speech, roundtable, etc.)

    Presentation Details (Length, Q&A, etc.)

    Speaker Line-Up

    Important Deadlines

    Your Audience

    Size of Audience

    Who will be in the audience? (clients, industry leaders, etc.)

    What is your speaker budget?