Speaker Request Form

Dr. Dickerson is delighted that you would consider him to speak during your event. We request that you complete the form and our administrative team will contact you soon. Please note that this form is a request for information and should not be considered a confirmation of attendance.

Contact Information

Please provide the name and information of the person who will be the primary contact for this event.

Primary Contact Name (First and Last):

Primary Contact Phone Number

Primary Contact Email

Ministry/Organization Information

Please tell us about your ministry or organization.

Name of Ministry/Organization

Host Name

Host Last Name:

Ministry/Organization Website

Ministry/Organization Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Ministry/Organization Phone Number

Ministry/Organization Email

Event Information

Please share with us details about your event.

Event Name

Is the event location the same as the ministry/organization address?

Yes

If you selected "No," please enter the location of the event below:

Multi-line address

Country/Region

Address

City

Zip / Postal code

Which of the following are you requesting Dr. Dickerson to do?

If you selected "Other," please specify below:

Type of Event

If you selected "Other," please specify below:

Event Attire

Event Date

Month

Day

Year

Event Start Time

Time

HoursMinutes

Event End Time

Time

HoursMinutes

Anticipated attendance for event

Will this event be broadcasted live via the Internet or Television?

Yes

How much time will Dr. Dickerson have for his portion of the event?

Additional Event Details (i.e. Theme, Purpose, etc.)

Please list the names of other participating speakers and their ministry or organization

Please feel free to upload any supplemental material for this request (i.e. Promotional Flyer, Speaking Proposal, etc.)