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Meet Dr. Teri
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Women's Health HERstory
Teri-fic Resources
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Coaching
Speaking
Consulting
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Teri-fic Tips
In Her Own Words
The Shop
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Meet Dr. Teri
Services
Coaching
Speaking
Consulting
Women's Health HERstory
Teri-fic Resources
Teri-fic Tips
In Her Own Words
The Shop
Contact
The Women's Health HERstory Advisor & Wellness Champion
Speaking Request Form
Name of Organization/Group
*
Group/Company Website
*
http://
Point of Contact
*
First Name
Last Name
Contact Email
*
Honorarium Budget
*
$250 - $1k
$1k - $2k
Business Structure
*
Non-Profit
For Profit
Event Name
*
Event Location
*
Type of Event
*
Date of Event
*
MM
DD
YYYY
Time of Event
*
Hour
Minute
Second
AM
PM
What role would you like Dr. Teri to play?
*
Check all that apply.
Keynote
Interview
Panel
Interviewer
Panel Facilitator
Breakout Facilitator
Other
Topic of Interest/Customized Topic
*
Dr. Teri's Speaking Time One
Hour
Minute
Second
AM
PM
Dr. Teri's Speaking Time Two
Hour
Minute
Second
AM
PM
Dr. Teri's Expected Speaking Duration
Thank you!
