Speaker Request Form

Please complete as much as the form as possible. Should you have any questions,

email Dr. Archie Ervin at awervinjr@gmail.com. Thank you.

Name*

Company/Organization*

Email*

Best Number to Contact You*

Company/Event Website*

Name of Event/Theme

Date of Event

Time of Event

What is the target audience?

Executive Leaders

Mid Level Leaders/Managers

Women Leaders

Faculty/Staff

Student Group/Organization

BRG/ERG/Affinity Group

If other, please note in the following field.

Other

Approximate Number of Attendees

In what capacity would you like Dr. Ervin to contribute?

Keynote

Conference Emcee

Panel

Moderator

Workshop/Training

Breakout Session

If other, please note in the following field.

Other

What is the duration of time you are requesting Dr. Ervin's presence?

Is this a live or virtual event?

Will this event be recorded?

Dr. Archie Ervin

(919) 358-1288