The WealthyDentist.com™
Dental Speaker's Agreement Request

To request a speaker's agreement, please complete the following form:

Speaker's Agreement Request Form:

* Required
Select a minimum of one topic area:
Topic Category #1:*  
Topic Category #2:  
Primary Contact Information:
Organization's Name:*  
   
First Name:*  
Last Name:*  
Title:*   Dr. Mr. Mrs. Ms.
Designation:*   D.D.S. D.M.D.  Other
Your Position in the Organization:*  
Direct Access Phone #:*    Ext:
Primary Email Address:*  
Primary Office Contact Information:
Address Line #1:*  
Address Line #2:  
Address Line #3:  
City:*  
State or Province:*  
Postal Code:*  
Country:* USA  Canada  Mexico
 Australia New Zealand
 Great Britain  Other
Phone #:*  
FAX #:  
Web Site Address:  
              (www.Dental-Care.com)
Fee Schedule:
Jim has two fee schedules - based on your organization's attitude about speakers promoting their products from the stage.  Please select the one that best meets your needs:

  1.  For organizations who frown, disapprove of, or discourage speakers from promoting their services or products from the stage, Jim's rate is $10,225 a day. 
 

2.  For organizations that will allow speakers to promote their services and products in a tasteful, non-confrontational and mannerly way, the fee is $4,500 a day.  This includes a sales table in the back of the room where doctors can view samples and place orders.
Meeting Information:
# of Dentists expected at Jim's speaking session:*  
Speaking date(s) of Jim's session(s):*  
# of sessions:*  
Meeting's location:*  
A description of your organization's purpose:*  
Comments:  

 06/19/2009 09:13:39 AM
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Your First Name
(no initials, please)

Your Last Name
D.D.S.D.M.D.Other
 

Your Primary Email

Office Fax Number


Email
 

 


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