Formal Speaker Invitation- Dr. Joia

Date *

Sponsor *

(Provide the name of host organization, street address, city state, zip code)

Sponsor or Event Website

Speaker *

How did you hear about the speaker?

Event Date(s) *

In-Person or Virtual Event

Event Description *

(Type: Lecture, Reading, On-stage Conversation/Interview. Include full schedule and times, and ALL ACTIVITIES – including receptions, dinners, signings, class visits, etc.)

Purpose of the Talk/Event *

Event Time(s) *

Event Platform *

Instructions for Event Platform *

Event Venue/Location *

Venue Capacity *

Honorarium *

NOTE: In addition to honorarium, Sponsor agrees to pay the following travel expenses: Round trip first- or business-class flights (If the purchase of first or business-class flights are prohibited by your organization, please note above), hotel, meals, commercial/licensed local and airport car service in event city, and airport transportation in departure and home cities. Sponsor will assume the cost of ONE change; costs associated with subsequent changes will be the responsibility of the Speaker.

What Message do you hope Dr. Joia delivers? *

(Please provide name, address, phone and website if available)

Powerpoint (YES OR NO) *

Deadline for Powerpoint presentation to be submitted *

Contact for Content Questions *

Would you consider someone (non MD) other than Dr. Joia? *

Nearest Major Airport *

(Please also indicate distance from airport to venue)

Hotel Accommodations *

(Please provide name, address, phone and website if available)

Audience Profile *

Number of Attendees *

Public Event *

YES
NO

Ticket Price

If Applicable

Past Speakers *

Please describe your COVID-19 protocols *

Speaker Attire (mark one): *

Sponsor Contact Information

Sponsor Contact Name *

Title *

Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Signature

Name and Title of Individual Responsible for Signing Contract *

By signing below you acknowledge that this Speaker Booking is a FIRM offer. If Speaker accepts this offer, a binding contract will subsequently be formed. Conditions of the contract will stipulate that 50% of the fee will be due to Speaker upon signature of the contract and 50% will be due no later than the day of the event and must be received by Speaker no more than three (3) days after the event. You represent that you have the requisite authority to enter into such a binding contract. This firm offer form must be filled out and signed by someone with the requisite authority. THIS IS NOT A CONTRACT *

Signature

Date

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