Speaker Booking Interest Form - Dr T Medley
Thank you for your interest in booking Dr Ticily Medley for your event.
Please fill out the information below to aid us in determining how we can support your event.
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Email *
What is the name of your organization? *
Name and Title of the primary contact person for your event or organization. *
Email address for the primary contact person. *
Phone number(s) for the primary contact person. *
How did you hear about Dr T/New Day? Who referred you?
What is the name/title of your planned event? *
What is the date and time of your planned event? NOTE: If your dates are tentative, that's ok, just list all preferred dates and times and label them "tentative". *
What is the location of your planned event? Please provide a full physical address and a building name (if applicable). Alternatively, indicate if your event is expected to be virtual/online. *
What topic(s) would you like Dr Medley to cover during your event? Or, if you're requesting a specific workshop title, please indicate which workshop. Also, what is the role you want Dr. Medley to play in your event: keynote address, workshop, training, expert panelist, event host? *
Any additional comments, requests, or questions can be entered here.
Enter today's date below. 
* NOTE: If you don't receive an email or phone response within 2 BUSINESS days, please follow up with an email inquiry to INFO@DrTMedley.com
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We look forward to serving you and your organization! Be sure to click the SUBMIT button at the bottom of this page.
Contact:
Dr. Ticily Medley
PO Box 181217
Arlington, TX 76096-1217
INFO@DrTMedley.com
www.DrTMedley.com
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