* denotes required field
Name *
Your relationship to/role within the event *
Email address *
Preferred contact phone number *
Address *
Website
Phone
Fax
Organizational/denominational affiliation
How did you hear about Alicia's ministry?
Why would you like Alicia to speak at this event?
Name of Event or Conference *
Event Website (if any)
Dates you are requesting Alicia to minister/speak 2008 2009 2010 2011 2012 2013 2014 2015
Description of your event *
History of event (previous speakers and attendance)
Number of times you are requesting Alicia to speak *
Approximate length of each speaking session *
Profile of participants
Anticipated attendance
Is there a particular theme you would like Alicia to address? *
City, State, Country *
Name of Facility/Venue *
Venue Address *
Name and distance of nearby cities with major airline service *
May Alicia have tables to make her resources available? Yes No Not appropriate for event
Are you able/willing to provide airfare for Alicia and her assistant? Yes, for both Yes, for Alicia No
Are you able/willing to provide accommodations (1 shared room and all meals) for Alicia and her assistant? Yes No
For our budgeting purposes, please indicate your budgeted honorarium; (and please know that alicia does not accept or decline invitations based on finances)
Please feel free to include any other information that might be of interest concerning the nature and purpose of this event.
