Speaker Application Form

Dates of your Event?

(i.e. June 17-18, 2016)
TIme(s) of events
City/State of Event

(i.e. Atlanta, GA)
Venue

(i.e. World Congress Center)
Sponsoring Organization
Who does this event primarily target?
What is the projected size of the event?
Who else is speaking at this event?
Please describe the vision of your event and how you see Mishael Porembski fitting into the vision.
How much time will Mishael have to speak?
At what time(s) would Mishael be speaking?
What kind of media will Mishael be able to use while she's speaking?
(i.e. Can she show a video, or have a powerpoint presentation?)
Honorarium Proposed?
How many of Mishael's books would you like to purchase?

(books come in quantities of 25)
Mishael often travels with a staff or family member. Would travel expenses and accommodations for one additional person fit within the event budget?
What is the nearest Airport?
How did you hear about Mishael Porembski?
Would you offer exhibitor/booth space for 180 Your Life?
Contact Person Name
E-mail Address
Street Address
City, State, Zip
Organization Phone Number
Mobile Phone Number