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Appearance Request Form

Please share details about your appearance request by completing this brief form.

Your first name

Your last name

Company/Organization name

Phone number

Appearance date

Event start time

Time

HoursMinutes

Event end time

Time

HoursMinutes

Event name

Name of Venue of the event

Address where event will be held

Country/Region

Address

City

Zip / Postal code

Please provide a brief description of the event in which Dr. Burns-Wallace is requested to appear

Anticipated audience count?

Please enter the requested arrival time of Dr. Burns-Wallace

Time

HoursMinutes

Please enter the time Dr. Burns-Wallace will appear on program

Time

HoursMinutes

Please describe specific themes/focus areas and/or talking points you'd like Dr. Burns-Wallace to incorporate in remarks.

Will onsite guests have an opportunity to purchase Dr. Burns-Wallace's book, Made for This?

Yes

If "Yes," please indicate your preferred method of securing books in advance of event

Through bookstore partner

Through the Author

Please share the name of the bookstore partner

Please upload an event agenda, if available