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Inside Advertising Speakers Program

Participation Form

* = required field

Name: *
Title: *
Company: *
Address: *
City, State Zip: *
Phone #: *
Email: *
Assistant:
Assistant's Phone:
Assistant's Email:

I CAN SPEAK ABOUT (CHECK ALL THAT APPLY):

Account Planning Advertising Process Branding Creative
Digital Ethics in Advertising Ethnic Marketing Gender Portrayals
Global IMC Interactive Media
Persuasion Political Public Service/Non-Profit Social Media
Social Responsibility
Other
Please Specify:

WHICH ACCOUNTS ARE YOU CURRENTLY WORKING ON:

PLEASE LIST YOUR ALMA MATER(S):
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LIST COLLEGES/UNIVERSITIES THAT MEMBERS OF YOUR FAMILY ARE CURRENTLY ATTENDING:

DO YOU HAVE ANY OTHER EDUCATIONAL VISITS PLANNED? IF SO, WHEN & WHERE?

WHERE DO YOU RESIDE (CITY AND STATE)?
*

IS THERE ANYWHERE YOU TRAVEL FREQUENTLY?

DO YOU HAVE ANY GEOGRAPHICAL PREFERENCES FOR OTHER VISITS?

I AM WILLING TO DO A VIRTUAL VISIT (E.G., SKYPE, WEBEX, BLUEJEANS)

PLEASE LIST RECOMMENDATIONS FOR ADDITIONAL SPEAKERS, SPECIFICALLY FROM CLIENT COMPANIES. BE SURE TO INCLUDE NAME, TITLE, COMPANY AND EMAIL.

Recommendation 1
Name:
Title:
Company:
Email:
Recommendation 2
Name:
Title:
Company:
Email:

PLEASE EMAIL YOUR MOST RECENT BIOGRAPHY AND PHOTOGRAPH TO sp@aef.com