Full Name:*

E-mail address:*

Phone:*

Job Title:

Organization Name*

Industry

Event Name*

Event Date

To Be Confirmed

When required, please confirm if you will cover travel, accommodation and transportation cost?*
YesNo

What would you like for Amna to deliver at the event? *
Keynote SpeechPanel DiscussionWorkshopMC or ModerateOther

If other, please describe:

Length of speech required*

Who will be attending the event? (target audience, demographic…etc.)

Will media attend or cover the event?
YesNoNot Applicable

Will the organizer provide a photographer and/or a videographer*?
YesNo

If yes, do you agree to provide photographs and recorded material?
YesNo

Approximate Budget

Is there a specific topic or key message you want Amna to Cover?*

Please outline any additional requests here: