Speaker Request

Mind Proxy LLC

event
request

We appreciate your interest in inviting Mind Proxy LLC to participate in your event. All meeting, interview, and speaking requests must be submitted through this web form.

For any onsite or large conferences, and similar events, we request that you submit this form along with any supporting or proposed materials at least 12 weeks prior to the event date.

For singular-day webinars or smaller scale virtual or Zoom-type interviews, 4-weeks prior is acceptable.

Please note that all requests will be thoroughly reviewed before a final determination is made. Please be sure all initial Contact Details are correct as questions often are raised during the review process.

A letter confirming receipt of your request will be emailed to you after submission.

"*" indicates required fields

Purpose of Event Request*

Please indicate your goal or purpose in seeking Mind Proxy' participation.

Primary Contact or Event Host

Full Name*

Job Title

Company/Organization*

Host Time Zone*

Other Time Zone

Please indicate the time zone by name or UTC Code

Phone*

Type*

Text Message?

Email*

Enter Email Confirm Email

Host Website

Please indicate the main website for the Host Company or Organization

Event

Event Type*

Event Title*

Topic*

Recorded?

Will the Event be recorded and/or repurposed?

Repurposing

Please specifically describe how the video recording and audio will be repurposed. E.g., for Public or Private YouTube, Resold as part of course material, etc.

Event Sales or Informational Website

Please enter sales, ticketing, or informational website specific to the Event, if applicable

Onsite Participation?*

Please indicate if Mind Proxy is requested to be Onsite or to participate Virtually

Other Participants/Speakers?*

Physical Venue Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other Invited or Confirmed Participants

Please indicate both Name and Organization where applicable

Event Format

Interview/Fire Side Chat

Presentation

Seminar

Webinar

Roundtable

Speech

Workshop

Panel Discussion

Please tick all that apply.

Moderator's Name and Org

Title of Panel

Requested Date and Time

If the Event is multi-day or Mind Proxy is requested to participate in more than one session or program, please indicate this information in the Additional Details area at the bottom of this section.

Specific Date*

Time

Time Zone*

Duration of Event

Please enter the expected duration of the Event: Hours, Days, Weekend?

Indicate Other Time Zone

IS Audience Q&A Anticipated?*

Will there be questions from the audience?

Handouts?*

Are additional or instructional materials, notes or handouts required or expected?

Describe Other

Additional Details

About the Audience

Target Audience*

Social Media Handles

Please indicate the Host's or Event's various Social Media Handles as they relate to this request

Describe Mixed

Anticipated Number of Attendees*

Please approximate the number of attendees that have been at similar events you've hosted in the past.

File(s)

Drop files here or

Accepted file types: pdf, jpg, docx, Max. file size: 300 MB.

Please upload any supporting files, documents, resumés, marketing materials pertinent to consideration of this request.

Terms and Conditions

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Name

This field is for validation purposes and should be left unchanged.

Terms & Conditions

See full disclaimer

Submission of this Speaker Request Form is a request only and does not imply consent or agreement to participate by any representative of Mind Proxy LLC (MIND PROXY). MIND PROXY will consider each request to determine speaker availability and whether participation is in compliance with the rules, regulations, guidelines and/or governing principles of MIND PROXY LLC.

If and when MIND PROXY agrees to participate in the event, confirmation of its participation will be communicated in writing to the contacts provided.

MIND PROXY must review and approve in advance any public announcement, news release, invitation, promotional materials, or other information to be released regarding an appearance by MIND PROXY at the event.

The Requester may not use the name (including but not limited to website URL, images, headshots, testimonials, or logos) of MIND PROXY in any way that constitutes or implies endorsement by MIND PROXY of the Requester, the Requester’s Organization, the event, or any participant or topic connected to the event.

All press participation must be approved at least two weeks prior to the event by MIND PROXY. If you indicate in the Speaker Request Form that the event is not open to the press and subsequently open the event to the press, MIND PROXY reserves the right to unilaterally cancel its participation in the event.

The Requester will inform MIND PROXY if it intends to record or broadcast MIND PROXY’s participation, or reproduce or distribute any presentations or program material created or used by MIND PROXY in connection with a speech or its appearance.

The Requester agrees to cooperate with MIND PROXY with regard to any security arrangements at the venue or event that may be required or necessitated by MIND PROXY’s participation.

Gift, honorarium, expenses, reimbursement or compensation for participation, travel, lodging expenses in connection with this event will be detailed in separate “Compensation Agreement” documents, as needed or required. For additional information, please contact info@mindprxy.com .

The Requester understands and agrees that any material change to the information provided on the “Speaker Request Form” or any failure to comply with these Terms and Conditions may result in the cancellation of participation in the event by MIND PROXY and its representatives.

Either party may terminate this Agreement, for any reason or for no reason, upon not less than 45 days prior written notice to the other party with either party’s intention to terminate this Agreement.

The information you provide will be used to manage MIND PROXY’s participation at events. MIND PROXY securely maintains all personally identifiable information in its control and only shares it outside of MIND PROXY if required by law, regulation, or court order. For additional information, please contact info@mindprxy.com .