First Name:*

Last Name:*

Company/Organization:

Email Address:*

Telephone:*

Cell Phone:

Dates Available: You may list more than one Thursday - Speakers 1st, 3rd, 5th or Networking 2nd, 4th Thursday

Title of Presentation:*

Topic: (1-2 sentences on the subject of your presentation.)*

How does your topic relate to the business, spirituality and/or Networking with regard to the theme for this year?:*

Description of your presentation: (approximately 130 words to be used in Speaker brochure)*

Speaker Biography: (to be used in Speaker brochure)*

Introduction: (if different from speaker biography)

Speaking Reference No. 1 Name:*

Reference #1 Phone Number:*

Reference No 1 Email Address:*

Speaking Reference No. 2 Name:*

Reference No. 2 Phone:*

Reference No. 2 Email Address:*

If selected to speak or facilitate networking at BHS, I would like to be gifted with one of the following:

$25.00 Gift Certificate from the Higher Shelf
BHS Recognition Table the day of my presentation

I have read the Speaker/Networking Facilitator's Code of Ethics and accept all stipulations:

Yes No

I will not spam the group with my company's work:

Yes

I am responsible for any sales tax resulting from any sales generated at BHS:

Yes

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