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Speaker Registration Form

Complete the form below to register with Leading Authorities! (You can call us to charge the registration fee on a credit card) Please call 1-800-SPEAKER if you have questions

Your Information

First Name:
Last Name:
Address1:
Address2:
City
State:
Zip:
Country:
Phone:
Fax:
Your email address:
SS/Federal ID#:
Subjects:

Previous Speaking Experience

Organization 1:
Contact 1:
Telephone 1:
Organization 2:
Contact 2:
Telephone 2:
Organization 3:
Contact 3:
Telephone 3:

Please check the materials you will be sending**:
	Biography
	Color Photograph
	Video of Speech
	B & W Photograph
	Outline of Speech Topics
	Letters of Reference

Additional Information

What is your speaking fee?
Do you have any geographic limitations?
Do you have any time constraints?
What audio/visual equipment do you require?
What type of speaking engagement do you prefer?

Contact Person Other Than Yourself

Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
I verify that the information contained in this registration form is accurate and truthful. By submitting it, I authorize Leading Authorities, Inc. to promote me as a potential speaker to its clients and prospective clients and to include my photograph, name, voice and moving image in the company's catalogs, correspondence, multimedia presentations, promotions, press releases, electronic and fax communications, and other promotional activity*.

* = this information is required!
** = Please send your materials under separate cover to:
   New Speaker Registration
   Leading Authorities, Inc.
   1220 L Street, N.W., Suite 850
   Washington, DC 20005-4070. USA