Dana Pittard

Contact Person/Responsible Party *Please include first and last name
Name of Hosting Organization *
Email *
Confirm Email *
Phone *
Confirm Phone *
Type of Company or Organization *
School | School DistrictCollege/UniversityMilitary InstallationMilitary Affiliated Organization or GroupCorporateNonprofitSmall BusinessPersonal | Private EventOther (if other, include in the next section)
Other company or organization type if applicable

Type of Event (check all that apply) *
Campus/School EventChurch/Religious EventLuncheon/Dinner/BanquetExpo/ConferenceSeminar/WorkshopPanel DiscussionTown Hall / RoundtableOnline/Webinar/VideoconferenceGuest: Talk Show/TV ShowGuest: Podcast/Radio ShowWriter Request/Blogger/ColumnistInterviewOther (please describe below)
Title of the Event *
End Time of Event *HHMM
Theme (if any) *
If you require specific topic/talking points, please provide more details
Type of Presentation Requested *
News InterviewKeynote PresentationPanel DiscussionInteractive half-dayFull DayRetreatTrainingConsultingOne on One | Corporate Type Mentoring or CoachingAfter the Keynote - Follow-upBreakout SessionsOpening RemarksClosing Remards
Objective | Purpose of the Event *
Date of Event *
Start Time of Event *HHMM
Time Speaker is Needed (Arrival, etc.) *HHMM
Speaker's Allotted Time to Speak (if applicable) *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Is a PowerPoint presentation requested? *
YESNO
Are other speakers/panelists scheduled for this event? *
YESNO
If so, who and in what capacity? If no, write: N/A

What is the demographic of your audience? *
Expected Audience Size *
One-on-One MentoringSmall Group (2-10)11-2021-3031-4041-5051-100101-150151-200201-300301-400401-500501-750751-10001001-20002001-30003001-40004001-50005001 +
Attire for this Event (if applicable) *
BusinessCasualBusiness CasualDressy CasualSemi-FormalFormal (Black Tie optional)Black TieWhite Tie
Is media coverage expected? *
YesNo
Is adequate security provided for this event? *
YesNoNot applicable
Will the event be videotaped? *
YesNo
Will the videotape be available for sale to the public *
YesNo
Is the speaker allowed to sell merchandise (books/shirts) at this event? *
YesNo
Is there a request for the speaker to be available for the media, advertising, or any other public appearances pertaining to this event? *
YesNo
Ground Transportation Available *
Airport ShuttleTaxiEvent host will provide transportationSpeaker will provide transportationNot applicable
Speaker Agent Information If you have questions or need additional information, please feel free to contact: Monica Tucker Speaker Agent | Sun City Speakers MOCHA Enterprises monica@suncityspeakers@gmail.com suncityspeakers@gmail.com 915.345.1661 Office 915.867.6292 Cell