Request for Speaker Dr. Jacob Atem Speaker Request FormPlease enable JavaScript in your browser to complete this form.Email *Name *FirstLastProfessional Title / Affiliation (i.e., Company, School, University, etc..) * *What is your organization type? *ChurchPublic SchoolUniversityOtherIf You Selected Other Please SpecifyAre You Providing A Speaker Fee? *YesNoOtherIf You Selected Other Please Specify Contact Jacob for pricing: 517-243-3118Phone Number *Preferred Speaking Date *Backup Speaking Engagement Date (leave blank if not applicable)In order to provide the best speaker experience, the following audio, and visual equipment is recommended - please checkmark which applies to your event location so Jacob can best facilitate *SpeakersInternet AccessMicrophoneComputer AccessLaser PointerSlide ClickerOtherIf You Selected Other Please Specify Event Address (confirm directions with speaker) *Please indicate your organization's willingness to support speaker's travel arrangements (choose as many as you like) *AirfareHotelRentalOtherIf You Selected Other Please SpecifyPlease provide why you are requesting Jacob to your event (i.e., how did you find out about him)? Is there a theme tied to this request? How long would you like the talk to last? Please add any additional comments as needed to help us plan for your event *Submit
