Apply to be Represented by Speakers Plus! Contact Info Name: E-mail: Web site: Company: Mailing Address: Office Phone: Cell Phone/Beeper: FAX: Best Time to Call: Weekday mornings Weekday afternoons Other (Please specify) About Your Expertise and Experience List your primary area of expertise: List Your Top 3 Presentation Topic Titles: Speaking category: (Check all that apply) High achieving women Motivation/Inspirational Voices for Higher™ Workplace productivity Health/Lifestyle management Trainers and consultants Media, politics, and current events Other (Please specify below) Years as a speaker: Fee Range: $20,000 and above $10,000 to $20,000 $5,000 to $10,000 $1,500 to $5,000 Below $1,500 Additional Remarks:

Speakers Plus! Worldwide Speakers Bureau Phone Int'l: 1-757-312-9589, USA: 800-225-2338 | www.SpeakersPlus.com © 1996-2003, Speakers Plus! All Rights Reserved.