Book Jason to Speak at Your Event

* Organization to be addressed:

* Requested date(s):

* Type of presentation
(What is your organization interested in learning?):

* Contact name:

* Contact's phone number:

* Contact's email address:

* Contact's cell phone on day of presentation:

* Location of presentation:

* Address:

Cross streets or significant landmark:

Parking information:

Speaker check in information:

* Type of event:

* Event start/end time:

* Presentation start/end time:

Number of attendees:

Will the media be in attendance?

Will audio/visual equipment (i.e. laptop, projector and screen)
be provided?

How did you hear about this opportunity?

Other:

* I hereby unconditionally authorize and consent to Jason L. Meriwether using videotape, audio, photographic, electronic and/or any other media image, quotations, likeness, or electronic or photographic reproduction in any manner, in whole or in part, for any and all educational, promotional, marketing, news, or outreach activities.