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GenieSpeak - Genealogy Speaker Registration Form

Print form (set printer to portrait). Type or print plainly and send to:
GenieSpeak ,%Helen Staiger, 240 Duffy Rd, Slippery Rock, PA. 16057
Fax (724) 794-4627 (press SEND as soon as phone rings or our answering machine may pick-up)

Name:

Address:
Payment Method: One Time $25 Registration/Setup Fee: Check (payable to Helen Staiger) or Paypal ________________

PHONE: Home#:____________________________________Business#:______________________________

E-mail address:_____________________________________Fax#:___________________________________

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 specialties:

.
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: local________ regional________ national________

Will you provide a sample audio or video tape for review upon request?_________
For what fee?__________ Is this refundable if they schedule you to speak or if they return it postage paid?________
Are your speaking fees negotiable dependent on the size of the organization or audience?___________

PLEASE NOTE: Include all information requested. Mark any items you wish to be kept confidential as such. Otherwise all information will be listed on the website.