SPEAKER REQUEST FORM
Imani Enterprises
2840 Stone Bridge Trail
Conyers, Georgia 30094
770.309.6664 Office
678.413.1230 Fax
www.TeacherTransformation.com
*Print this form, fill it out and fax it to 678.413.1230.
Contact Person: ____________________________________________________________________________
Organization: ______________________________________________________________________________
Mailing Address: ___________________________________________________________________________
City: ______________________________
State: __________Zip: ___________
State: __________Zip: ___________ Phone: Office: ______________________________Cell: ________________________
Cell: ________________________Email: ____________________________________ Fax: ________________________
Fax: ________________________**********************************************************************************************************************************
Event: ____________________________________________________________________________________
Conference Theme: ________________________________________Date of Event: _________________
Date of Event: _________________Location of Event (Venue): __________________________________________________________________
Address of Venue: __________________________________________________________________________
City: _____________________________________State: __________Zip: __________
State: __________Zip: __________Number of people expected to be in attendance: ______________
Will there be an opportunity for vending?: ____________
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Presentation Requested:
_____Keynote Speech_____Conference Workshop_____ Professional Development
Keynote Speech_____Conference Workshop_____ Professional Development_____Presentation to Students_____ParentPower! Presentation
Presentation to Students_____ParentPower! PresentationHow did you hear about Chike Akua?
_____I saw Chike speak at a school/conference. Which school/conference? __________________________________
I saw Chike speak at a school/conference. Which school/conference? _______________________________________ReferralWho referred you? ________________________________
ReferralWho referred you? _____________________________________ WebsiteWhich website? ___________________________________
WebsiteWhich website? ________________________________________Other ____________________________________________
Other ____________________________________________*Fax this form to 687.413.1230
Find out why Chike Akua is one of the most sought after keynote speakers at educational conferences, colleges and universities and
k-12 schools!
