™ 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):

    Designation (required):

    Your Position in the Organization (required)

    Direct Access Phone # (required)

    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):
    USACanadaMexicoAustraliaNew ZealandGreat BritainOther

    Phone # (required)

    Fax #

    Web Site Address

    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 (required)

    # of Sessions (required)

    Meeting's Location (required)

    A Description of Your Organization's Purpose (required)


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