Speaking Engagement Request Form

David Agron, Ph.D.

[email protected]  |   [email protected]

(626) 617-0527   |  (800) 251-0255


    Date of Request*

    Date of Function*

    Organization*

    Contact Name*

    Email*

    Phone*


    Function

    Theme/Topic

    Location

    Audience (size, age range, etc.)

    Number/length of messages

    Function Schedule

    Time Dr. Agron will speak

    Dress code

    Book Sales Table ApprovedDenied

    Will function be recorded? NoYes (audio)Yes (video)
    If Dr. Agron's material is recorded,
    • Dr. Agron grants permission for your internal use and distribution
    (e.g., copies given or sold to church members but not sold online or at other venues)
    • Dr. Agron must receive a copy that can be reproduced and use with full rights


     

    Compensation

    Accommodations

    Meals

    Transportation

    Method/Time of payment

    Any additional information you need from Dr. Agron