TheWealthyDentist.com™ Dental Speaker’s Agreement Request

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

Select a Minimum of One Topic Area

Topic Category #1 (required):

Topic Category #2:

Primary Contact Information

Organization's Name (required)

First Name (required)

Last Name (required)

Title (required):
Dr. Mr. Mrs. Ms. 

Designation (required):
D.D.S. D.M.D Other 

Your Position in the Organization (required)

Direct Access Phone # (required)
  Ext:

Primary Email Address (required)

Primary Office Contact Information

Address Line #1 (required)

Address Line #2

Address Line #3

City (required)

State or Province (required)

Postal Code (required)

Country (required):
USA Canada Mexico Australia New Zealand Great Britain Other 

Phone # (required)

Fax #

Web Site Address
(www.mywebsite.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.

 1. 2.

Meeting Information

# of Dentists Expected at Jim's Speaking Session (required)

# of Sessions (required)

Meeting's Location (required)

A Description of Your Organization's Purpose (required)

Comments

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