SPEAKER REQUEST FORM

Imani Enterprises
2840 Stone Bridge Trail
Conyers, Georgia 30094
770.309.6664 Office
www.MyTeacherTransformation.com 



*Email this information to info@myteachertransformation.com.

Contact Person: ____________________________________________________________________________

Organization: ______________________________________________________________________________

Mailing Address: ___________________________________________________________________________

City: ______________________________State: __________Zip: ___________

Phone: Office: ______________________________Cell: ________________________

Email: ____________________________________  Fax: ________________________

**********************************************************************************************************************************
Event: ____________________________________________________________________________________

Conference Theme: ________________________________________Date of Event: _________________

Location of Event (Venue): __________________________________________________________________

Address of Venue: __________________________________________________________________________

City: _____________________________________State: __________Zip: __________

Number of people expected to be in attendance: ______________

Will there be an opportunity for vending?: ____________

**********************************************************************************************************************************
Presentation Requested:

_____Keynote Speech_____Conference Workshop_____ Professional Development

_____Presentation to Students_____ParentPower! Presentation

How did you hear about Chike Akua?

_____I saw Dr. Akua speak at a school/conference.  Which school/conference? __________________________________

_____ReferralWho referred you? ________________________________

_____ WebsiteWhich website? ___________________________________

_____Other   ____________________________________________

*Email this information to info@myteachertransformation.com.


Find out why Dr. Chike Akua is one of the most sought after keynote speakers at educational conferences, colleges and universities and 
k-12 schools! Whether speaking to teachers, parents or students, get ready for transformation!