Special Guest Form

Thank you for being willing to come onto our show and engage with our audience.

This form is to grab some details:

Topics and Questions you'd like covered
Your details so we can promote you properly on Social Media and our site.
One or more photos we can use.

At the end, you'll be redirected to a calendar to book your time slot.

Fill in your details

First Name *

Last Name *

Phone

Please enter your phone number in the international format. (+country code + number). We can send you SMS reminders (if you're not in the USA), and Patrick can call you in case of emergencies.

Email *

I consent to being communicated with using the contact details I provide.

Your business name

Your Business Website *

Please provide URL

Country *

Name as you'd like it to appear

Eg Name, Title, Company (Patrick van der Burght CLT, Ethical Persuasion Training)

How would you like us to introduce you? *

A short. 1 or 2 paragraph introduction, listing your achievements and credentials

Upload a photo we can use to promote you *

PNG, PDF, JPEG or JPG

What is the main topic you'd like to discuss? *

What are the three questions you'd like me to ask you? *

What are other questions related to your topic?

Well done. Now, let's talk about how we can promote you...

List all Social Media Links you'd like us to promote for you.

Name(s) + URL(s) please (eg Youtube: https://www.youtube.com/@ethicalpersuasion)

Did you author any books?

Provide the title(s) and, if you like, links for more info

Do you have a Give-Away for our audience?

Perhaps a download, information sheet, hidden video? Provide description and URL is needed.

Will you be promoting the episode across your social media platforms? *

Yes

Will you leave a review on Spotify and Apple Podcast on our show once your episode is published? *

Yes

Just one more...

Authorisation Consent: I hereby voluntarily and without compensation, authorise voice and video recording(s) to be made of me. I hereby give permission to use, reproduce and distribute the voice recordings, including my name and photo(s). I hereby agree to release the “Ethical Persuasion Unlocked”, “Patrick van der Burght”, “Ethical Persuasion Training and Consulting” or the company Blue Remora Pty Ltd and its employees, from any claims, damages or liability arising out of such use or distribution. I will take full responsibility for what I say or provide. I understand that the use of my name, likeness and voice and video recordings will be primarily for the purposes of commercial use, education and/or promotion. I have read and understand the foregoing and I consent to the use of my picture and/or voice as specified for the above-described purposes(s). I further understand that no royalty, fee or other compensation shall become payable to me, and that published content will not be removed later.

Yes I agree to the Authorisation Consent

You made it!