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* 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.Primary Contact Name* Primary Contact Email* Primary Contact Phone*Secondary Contact Name Secondary Contact Email Secondary Contact PhoneBio* 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 MarketsSelect the market specific to your speaker role. California Massachusetts Pennsylvania Texas National Conference (virtual) Speaker RoleSelect 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 Speaker Classification Board Member Community Partner Government Official In-Kind Sponsor Non-Sponsor Sponsor SessionSelect 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 Nat’l Conf Video Recording 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.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.Recording 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. Mailing AddressPlease provide a mailing address where we can ship equipment for your session recording, if applicable. Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please provide (3) dates with PST times you would be available to dedicate a maximum of 60 minutes to record this session prior to December 1, 2024. For those with Executive Spotlight Roles to be played at LIVE Conferences, please provide dates to record sessions prior to September 2, 2024 for Texas; October 7, 2024 for Pennsylvania; November 12, 2024 for Massachusetts and January 10, 2025 for California.*Note: While we can record up until this date, we strongly encourage all speakers to record as early as possible. Add RemoveWhat device will you be using for your recording? i.e. Computer, iPad, iPhoneThis will determine the type of equipment we send to you. 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. PhoneThis field is for validation purposes and should be left unchanged.