If you are interested in having Dr. Regina speak at your next event, please fill out the form below. You may also mail your request to:Regina Spellmon MinistriesP. O. Box 470513Fort Worth, TX 76107 Name * First Name Last Name Email * Church/Organization * Phone * (###) ### #### Checkbox * Keynote Speaker Panel Workshop Emcee Video, Podcast, or Online Webinar Date of Event * MM DD YYYY Please tell us more about your event (purpose, vision, how often the event is held...) * Is there a theme or a particular topic that you'd like for Dr. Spellmon to speak about? * Time of the Event * Hour Minute Second AM PM Time (s) Dr. Spellmon will speak * What time will you need Dr. Spellmon to arrive? * How long will Dr. Spellmon have to speak? * Venue Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Venue Type * Church Theater Event Center Outdoors Other What is the seating capacity of the event site? * What is the expected number of attendees? * Is there a registration fee? If so, how much per person? * Will the staff of Dr. Spellmon need to pay and register? * Yes No Shipping Address (Where we would mail promotional materials, etc) * Will Dr. Spellmon be able to sale merchandise at this event? * Yes No If yes, will a table be provided? * Yes No N/A Will an honorarium be given? * Will a W-9 be needed? * DUE TO THE MANY REQUESTS FOR DR. REGINA SPELLMON, WE ASK THAT A $100 NONREFUNDABLE DEPOSIT BE SENT WITH THIS SUBMISSION. PLEASE SUBMIT DEPOSIT VIA WWW.PAYPAL.COM TO REGINA.SPELLMON@YAHOO.COM. THIS WILL SECURE THE DATE AND HAVE IT ADDED TO DR. REGINA’S SCHEDULE. THE REMAINING BALANCE OF HONORARIUM IS DUE THE DATE OF EVENT. Yes, I will send the deposit No, I am unable to send the deposit I THE UNDERSIGNED, HAVE READ, UNDERSTAND, AND ACCEPT THE RESPONSIBILITY OF FULFILLING ALL REQUIREMENTS THEREIN. I UNDERSTAND THAT I WILL NOT BE ADDED TO DR. REGINA'S CALENDAR UNTIL MY DEPOSIT HAS BEEN RECEIVED. * Full name of person submitting request Thank you!
