Organization

First Name *

Last Name

Email *

Phone *

Name of Event or Website URL (if applicable) *

Type of event and Mel's speaking role

Event Date(s) *

Desired Date of Mel's Presentation *

Event City *

Event State *

If Outside USA, Please Add Your Event *

Approximate # of attendees for presentation

Approximate # of attendees for entire event (If applicable)

Audience Description *

Budget Range *

Theme/Topics of Interest *

About Us / Mission *