Speaking Engagement Request Form

To assist Dr. Tate in serving your needs and representing your group in the best possible fashion, please complete this form as part of an invitation for Dr. Tate to speak as a guest speaker, panel discussion and/or attend an event, or meeting.

While Dr. Tate openly accepts the vast majority of invitations that are made, he must frequently decline an invitation due to a calendar conflict. Dr. Tate attempts to accommodate most requests that support your mission and appreciates your patience with Dr. Tate’s complex calendar.

There are 3 key presentations Dr. Tate has developed, they are:

1. Free Your Mind and Release the Grief.
2. What to say and NOT to say to a grieving person.
3. How professional operators can keep a cool head, steady hands and a balanced temperament under stress.

Please submit an official copy of the program/invitation at least 6 weeks in advance of the event to
donaldtate2@gmail.com.

Event Name: *

Event Location: *

Event Date: *

Name of person or group requesting: *

Event Start Time (Include AM or PM): *

Event End Time (Include AM or PM): *

Dr Tate's participation / involvement requested from (Include AM or PM): *

What time will the majority of guests arrive? (Include AM or PM): *

TRAVEL: Includes expenses for round-trip business class airfare from Orlando FL, ground transportation, meals and tips. Expenses will be submitted under a separate cover preferred per dim of $150 per day in advance. Minimum 2 days per dim over 150 miles outside of Orlando. HOTEL: Arrangements to be made by the client and direct-billed to the client’s master account. Please reserve a king or queen size bed, non-smoking room, with late check-out approved. Dr. Tate will check in the evening before the event. NOTE: The times requested for Dr. Tate’s participation should be as exact as possible, as Dr. Tate is often juggling multiple events. If the event schedule changes after submitting this request, it is the even coordinator responsibility to contact Dr. Tate’s office at (571) 969-7766 immediately to see if the change can be accommodated.

Contact Person: *

Phone Number: *

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Email (one email address): *

Person who will meet Dr. Tate at the event: *

Dress Code: *

Business Professional
Business Casual
Casual
Formal

History of this event (inaugural, annual, etc.) *

Is Dr. Tate being requested to speak?

(If YES, please answer remaining questions. If NO, then proceed to bottom and click submit.)

Does the group have any special interests or concerns that should be addressed?

Is there a topic or subject that should be addressed in Dr. Tate’s remarks?

Should remarks be formal or conversational?

Preferred length of comments:

Expected Attendance:

Age Group of Audience:

Yes, I want to submit this form

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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