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GenieSpeak - On-Line Genealogy Speaker Registration Form

(PLEASE NOTE: Include all information requested. Mark any items you wish to be kept confidential as such with a "*C*". Otherwise all information will be listed on the website. Enter information as you wish it to appear on the webpage. What you type is what will show up. NOTE: GenieSpeak reserves the right to edit information for space considerations.)

New Registration (yes/no):
Revision (yes/no):

Payment Method (One Time $25 Registration/Setup Fee): Check or PayPal (see below):

Full Name:
Address:

Phone: Home number:

Business number: Fax number:

Email address: WWW address:

Background Information (check all that apply):

Professional Genealogist	Family Genealogist	Author
Researcher/Consultant	Lineage Expert	Teacher
Librarian/Historian	Government Employee	Vendor

List your specialities (100 words or less):

Lecture Topic Categories (check all that apply):

Beginners	Methodology	Regional/Ethnic
Time Period	Military	Immigration/Naturalization
Computers/Technology	Humorous	Societies/Associations
Professional	Specialized	Education/Certification

Will you travel:(check all that apply): Local: Regional: National:

Will you provide a sample audio or video tape for review upon request?(yes/no) For what fee?
Is this refundable if they schedule you to speak or if they return it postage paid?(yes/no)
Are your speaking fees negotiable dependent on the size of the organization or audience?(yes/no)

How did you hear about us?

REMEMBER: Please submit your scheduled speaking engagements as available for listing on the upcoming event pages, with a link back to your web site.

Enter payment information using the PayPal link below or on the Speaker Registration Info page.

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Then use your browser 'Back' button to return to our site.
A confirming email will be sent to you after payment is received and we enter your information on our site.

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