Speaker: 

Dr. Beverly Smallwood

Title/description of event: 

Dates(s) of engagement:

Time(s) and duration(s) of presentation:

Presentation title:

Audience:

Name of organization:

Name, address, and phone of person to whom correspondence regarding billing should be addressed: 

I agree to pay the fees and expenses agreed previously agreed upon plus expenses (Expenses include round trip airfare and/or mileage from/to place of presentation; ground transportation; meals; hotel, other direct out-of-pocket expenses):

Yes 

FEES AMOUNT:
 

The fee is payable on the following terms: 

AMOUNT OF DEPOSIT 

AMOUNT OF BALANCE
 

Because of the potential loss of income to the speaker, cancellation of this date less than 30 days before the event carries a penalty of 25%, in addition to the deposit, plus all expenses incurred by the speaker in preparation for this date.

Audio-visual requirements:

Special Arrangements:

Dr. Smallwood will arrive at on:

She will be transported from the airport by:

If questions arise, speaker should contact:

Name:

Phone: 

Alternate contact: 

Alternate Phone:

If, through disaster, Dr. Smallwood is unable to appear, she will provide an equally qualified speaker for the meeting. There will be no recording devices of any kind unless approved by the speaker.

I agree to the terms specified in this contract:

Yes 
I'd like to suggest revisions

Approved by:

Title:

Date: