Virtual Speaker Invitation-Dr. Joia

Date *

Sponsor *

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

Speaker *

How did you hear about the speaker?

Event Date(s) *

Event Description *

(Type: Lecture, Panel, Virtual Book Signing ,Reading,Conversation/Interview. Include full schedule and times)

Purpose of the Event/Talk *

Event Time(s) *

Event Platform (What online technology system will you be using?) *

Instructions for Event Platform *

What Message do you hope Dr. Joia delivers? *

Powerpoint (YES or NO) *

Deadline for Powerpoint Submission *

Contact for Content Questions *

Audience Profile *

Number of Expected Attendees *

Public Event *

Virtual Book Signing *

Anticipated Book Sales

If Applicable

Speaker Attire (mark one): *

Honorarium *

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

Sponsor Contact Name *

Title *

Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Name and Title of Individual Responsible for Signing Contract *

If Speaker accepts this offer, a binding contract will subsequently be formed. THIS IS NOT A CONTRACT. *

Signature

Date