First Name:*

Last Name:*

Company/Organization:

Email Address:*

Telephone:*

Cell Phone:

Dates Available: You may list more than one date. We meet every Thursday (except Thanksgiving) at 7:00 a.m.*

Title of Presentation:*

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

How does your topic relate to business and spirituality?:*

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)

Reference No. 1 Name:*

Reference #1 Phone Number:*

Reference No 1 Email Address:*

Reference No. 2 Name:*

Reference No. 2 Phone:*

Reference No. 2 Email Address:*

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

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

I have read the Speaker'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

Comments: