Speaking Engagement Request

Please use this form to reserve your speaking engagement request and pay your $500 deposit. Note, you will also need to submit a signed copy of the speaker agreement that was separately emailed to you.

Booking Information

Please provide contact information for you and your organization.

First Name *

Last Name *

Your Email (Primary) *

Organization Phone Number: *

Organization Street Address: *

City *

Country (Work) *

State *

Postal Code *

Please provide information specific to the event the speaker will be attending.

Confirmed Date and Time: *

Name of requested speaker: *

Please provide the location of the venue:

Venue Address: *

Signed Speaker Agreement *

Cancellation Policy: If, for any reason, your Organization cancels the Event described above or is not able to proceed with the Event on the agreed dates after submitting this deposit, Heartbeat International (“Heartbeat”) will attempt to reschedule based on the availability of the requested Speaker. If an alternative date can be agreed upon, your deposit will transfer to the new Event/date. However, the cost of all non-refundable travel expenses incurred by Heartbeat for this event, including any fees or penalties incurred from cancellation, will be your responsibility. Furthermore, your organization will be responsible for any unanticipated additional travel expenses due to weather-related and/or cancelled flights to or from the event.

I have read, understand, and agreed to the terms above. *

Yes

Fee *

Banquet Speaker Deposit - $ 500.00

Total

Credit Card

If you have a PayPal account, you can click the PayPal button to continue. Otherwise, fill in the credit card and billing information on this form and click Continue at the bottom of the page.

Checkout securely. Pay without sharing your financial information.

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *