Short Form Application To Be a Speaker At the Trailblazer Summit and Symposium

So we may best serve you, kindly complete this form.

We are assembling the information for promoting the event, and as soon as the graphics are completed we'll send you graphics and swipe copy.

If you have not yet registered, please do so at Trailblazer Summit

In what industry are you a trailblazer or trendsetter. MAX four words. This is the industry in which you play, what you do, not a description of what you do. These are nouns, not verbs (nothing ending in ....ing). See the website to see what you are being asked for. Trailblazer Summit
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While there are questions we'll be asking you about how and why you are a trailblazer, if there are specifc questions you like for us to ask you, what would they be? We may or may not ask these, too. You can leave these blank, if you wish.

Question one
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Question two
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Question three
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Question four
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Full name
Email
Cell Phone – not for publiciation; so if we have to text you
Your website
While this is not a selling platform, you will have the opportunity to offer the audience a gift, or a giveaway, as a lead capture, if you wish.

If you have such a gift or giveaway, what is the name of it?
URL of your gift or giveaway
Additional comments
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