Name *

First Name

Last Name

Phone *

(###)

###

####

Status of Company or Organization

For Profit

Not For Profit

Event Type

In-person event

Virtual event

Will media be invited? *

Yes

No

To be determined

How would you like for Dr. Seleena to contribute to your event?

Keynote Speaker

Workshop Facilitator

Trainer

Panelist

Host/MC

Other

Will this speech be followed by a Q&A Session?

Yes

No

Will Dr. Seleena be allowed to promote any of her products or services?

WILL Dr. Seleena BE ALLOWED TO PROMOTE ANY OF HER PRODUCTS/SERVICES

Yes

No

Will travel accommodations be required?

Yes

No

Date & Deadline for Acceptance *

Please provide exact date

MM

DD

YYYY