Conferences for Women Speaker Form Please list your Name, Short Title, and Organization exactly as it should appear. This information will be published as written in all Conference materials. "*" indicates required fields HiddenUser Type external internal Speaker Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev.Other First Last Phonetic Pronunciation of Name* Pronouns Short Title* Organization* Speaker Cell Phone* We require direct cell phone numbers for all Conference speakers. We will only use this for necessary onsite contact. Please enter phone number in format 000-000-0000 Primary Contact Name* Primary Contact Email* Primary Contact Phone*Please enter phone number in format 000-000-0000Secondary Contact Name Secondary Contact Email Secondary Contact PhonePlease enter phone number in format 000-000-0000Bio* Upload Bio PDF Paste in Short Bio Bio upload*Accepted file types: pdf, Max. file size: 15 MB.Short Bio*Please provide a short bio of up to 100 words Headshot*Please upload your current headshot to be used on our website and app.Max. file size: 20 MB.Relevant CFW Markets*Select all markets that apply for your speaker role California Massachusetts Pennsylvania Texas National Conference (virtual) CCP/ERG Recording Speaker Classification* Sponsor Board Member Community Partner Government Official In-Kind Sponsor Media Partner Non-Sponsor Speaker Role*Select all that apply Keynote Intro/Remarks Executive Mentor Moderator Host Panelist Learning Burst Executive Spotlight Speaker VIRTUAL – Main Stage VIRTUAL – Host VIRTUAL – Executive Spotlight VIRTUAL – Learning Burst Podcast Session*Select all that apply Keynote Breakout 1 Breakout 2 Breakout 3 Learning Stage Small Group Networking Wellness Stage Other Other Session Session Time*Select all that apply 8:45am – 9:45am 10:15am – 1:15pm 1:45pm – 2:45pm 3:15pm – 4:15pm Other Other Session time* Contract Commitments*Select all that apply Book Signing Highlight Reel Meet & Greet Media Interview Newsletter Interview Nat’l Conf Keynote Replay Nat’l Conf Live Q&A Podcast Recording Podcast Replay Social Media Post Sponsor Breakfast N/A Book Title If speaker has authored a book, please provide the title(s).Contract*Max. file size: 20 MB.W-9 (Tax Form)*Max. file size: 20 MB.Total Fee* Honorarium* Total Fee (dollar amount only) Travel Stipend Amount* dollar amount onlyDeposit Amount* dollar amount onlyDeposit Due Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Deposit Invoice*Max. file size: 20 MB.Balance Amount dollar amount onlyBalance Due DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Balance InvoiceMax. file size: 20 MB.Additional Informationex. Moderator Assignments, Payment Details, Rider Requirements, Green Room Requests, Security, Hair & Makeup, etc.Will you be attending one of our 4 live conferences?* Texas Pennsylvania Massachusetts California N/A Would you like to be filmed with our professional film crew on site? Yes No, I’d prefer to record myself virtually” Recording InformationPlease identify 3-4 dates/times that you are available to dedicate a maximum of 60 minutes to record this session between October 7th and November 8th, 2024. We will work with the producer's calendar to select one time for recording. Calendar invite to follow.* Add RemovePlease identify 2-3 dates/times you are available for a 30 min prep call at least a week prior to your recording availability. This prep call will be with you and the CFW Program Director. Calendar invite to follow.* Add RemoveRecording Equipment Needs*In order to ensure the highest quality video, we require the following equipment be used during your session recording. Please select below which item(s) you would need for us to send to you. Ring light (or other professional quality lighting) Ethernet Cable (Speakers should be within 50ft of their router to use an ethernet cable during the recording) All of the above. None of the above. I have all these items. 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What type of laptop will you be working with?(i.e. Windows or Mac) – Please indicate model and year with your answer. What type of iPhone or smartphone do you have?(i.e. Android, iPhone 8, iPhone X, iPhone 11) Please indicate if you have a cable adapter that can connect your phone to your computer. Form Submitted by* NameThis field is for validation purposes and should be left unchanged.