Speaker Request Form

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May 18, 2012

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Name*
FirstLast
Phone
Email*
Website*
What type of of interview will this be?*
Will the interview be live or recorded?*
How will the interview be used?*
What type of marketing will you do and/or expect us to do?*
What topic are you interested in Dr. Daisy speaking about?*
What is the size of your audience?*
Why do you feel Dr. Daisy would resonate with them?*
What is the affiliate opportunity? (for online events/interviews)*
Will a recording and transcript be provided to us to use on our own?*
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