Instructor Contract Request

Contact Information

Organization Name*

Name*

First Last

Email*

Phone*

Phone Ext.

I have been working with the following speaker

Manager currently working with*

Name of coordinator/manager

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Coordinator/manager currently working with*

State*

Other*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Additional Information

Type of School/Organization*

Please Define

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Type of School/Organization*

Emergency Cell*

Billing Contact Information

Name of Person to Receive Invoice*

First Last

Organization

Billing State*

Other*

Billing Address*

Same as Contact Information

Street Address Address Line 2 City ZIP / Postal Code

Email to Send Invoice*

Email of Secretary

Phone of Payer*

Event Information

Type of Event*

Event Dates*

Enter as MM/DD/YYYY. To add additional dates, use the "+" (NOTE: All requests should be completed at least 60 days prior to the requested date of your training. You will need to have a training date in mind when submitting your request.)

Proposed Start Date	Proposed End Date

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Proposed Start Date

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Date Details

Speaking Site

Site State*

Other*

Site Address*

Same as Contact Information

Street Address Address Line 2 City ZIP / Postal Code

What is the most convenient airport to fly into?

Describe the Event

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Type of Audience*

Please select all that apply

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Type of Audience

Please select all that apply

Type of Audience*

Please describe*

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Age Group of Children

Please select all that apply

Age Group of Children*

Please Describe*

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Estimated Number in Attendance

Estimated Number in Attendance*

Start Time*

:

End Time*

:

Time Zone*

I need to

Request another type of event.

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Event Information - #2

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I have been working with the following speaker

Type of Event*

Hidden

Event Dates*

Enter as MM/DD/YYYY. To add additional dates, use the "+"

Proposed Start Date	Proposed End Date

Hidden

Speaking Site

Hidden

Site Address*

Same as Contact Information

Street Address Address Line 2 City ZIP / Postal Code

Hidden

Describe the Event - #2

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Type of Audience*

Please select all that apply

Hidden

Please describe

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Age Group of Children*

Please select all that apply

Hidden

Please Describe*

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Estimated Number in Attendance*

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Start Time*

:

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End Time*

:

Hidden

Time Zone*

Additional Information

CI attend

Any Conscious Discipline Certified Instructors within the area may attend and participate by observation at this training.

Quote

I have received a price quote for this training.

How did you hear about us?

Please describe

Any additional information that we should know?

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Instructor Request Form

Contact Information

Additional Information

Billing Contact Information

Event Information

Describe the Event

Event Information - #2

Describe the Event - #2

Additional Information