EmailMe Form - Five Capitals Speaker Agreement

Buyer's Name (the "Buyer") *

First Last

Buyer's Email *

Confirm Buyer's Email

Organization/Business Name

Type the name of your organization/business (if applicable)

What is the name of the event? *

What are the dates of the event? *

Where is the event being held? (Venue Name, City, State) *

What airport should the Speaker fly into? *

A representative of the Speaker will book the flights.

Is a hotel room provided? If not, where would you recommend? *

How many sessions will the Speaker be giving? What is the exact timing's of the Speakers sessions? Please include talk length and total session length. *

Will the Speaker need to rent a car? *

Other: Please specify. *

Is there anything else you need us to know? Do you have any questions or concerns for us? *

How did you hear about Five Capitals? *

Billing Details

Total Amount You Are Compensating Speaker *

$ Dollars

Please note: a $1,500 deposit is required to secure your Speaker. The deposit is applied towards this Total Amount. Remaining Balance plus Expenses will be sent by invoice after the event.

Deposit Payment Method (Please select one): *

Please invoice me for the deposit

I want to pay the deposit now by Credit Card to secure the Speaker. Note: will load a payment page on submission.

To secure your Speaker for the dates listed you must provide your deposit.

Billing Contact for Remaining Total *

The billing contact is who you want to receive invoices.

Billing Contact Name *

First Last

Billing Contact Email *

Confirm Billing Email

Billing Phone Number *

### - ### - ####

Enter your phone number.

Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Enter the billing address associated with your billing method.

Any notes about your billing information:

Consent *

I agree to receive communication and marketing emails from Five Capitals.

Agreement *

By submitting this form I confirm that I have read and agree to the terms and conditions laid out in the Speaker Agreement in its entirety.

Click here to view the Speaker Agreement.

Signature *

Clear

By signing above I agree that I have read and agree to the terms in the Speaker Agreement (the “Agreement”) and I hereby enter into this Agreement. I understand this Agreement is in effect for the Event indicated on this form, and future Events may require me to resubmit this form and agree to updated terms and conditions as the Agreement may be updated over time.