Speaking Request Form

Company/Organization Name *

Organization Type * Organization Type * School District University or College Non-Profit (Non-Religious) Non-Profit (Religious) Corporate Other

First Name *

Last Name *

Contact Email *

Contact Phone *

Contact Role or Title (within Company/Organization)

Street Address *

Address Line 2

City *

State / Province / Region *

ZIP / Postal Code *

Country

Company/Organization Website

Projected Budget for Securing Speaker(s) / Appearance(s) *

Does your projected budget include traveling expenses? Lodging (if needed)? * Does your projected budget include traveling expenses? Lodging (if needed)? * Yes No, we have a separate budget for travel/lodging

Event Date and Time *

Event Name

Event Description/Purpose *

Is this a virtual event? * Is this a virtual event? * Yes No

Number of Presentations/Appearances

Desired Topic(s) for Presentation *

Venue Name

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Number of Guests Expected in Attendance Number of Guests Expected in Attendance 100 - 250 250 - 500 500 - 1000 1000 - 2000 Other

Do you intend to record or live stream this event? * Do you intend to record or live stream this event? * Yes No

Can Beautiful Butterfly products be sold at this event? * Can Beautiful Butterfly products be sold at this event? * Yes No