Speaker Request Form Company Thank you for your interest in having Dr. Jaketha Farmer speak at your event. In order to help us make an accurate assessment of your speaking needs, please complete the online form below to providing as much information as possible about your event. Thank you in advance. Guard Your Heart Press http://www.gyhpress.com CONTACT INFORMATION: First Name: * Last Name: * Email Address: * Phone Number * Will you serve as Dr. Jaketha's primary point of contact? * Yes No Client/Sponsoring Organization Name: * Client/Sponsoring Organization's Website: * Client/Sponsoring Organization's Street Address City State / Province / Region - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code: EVENT INFORMATION: Event Name/Theme: * Event Description: * Audience Type: * Event Budget: Event Venue Name: * Event Venue Location * Event Start Date: * Event End Date: What would you like Dr. Jaketha to speak on? * Event name, theme, frequency event, etc. Will Dr. Jaketha and/or her staff be able to sell products at this event? * NOTE: A standard table will be needed if applicable.