Speaker Form Please make sure to list your name, short title, and company as we will use as written for all conference materials. Speaker Name* First Last Phonetic Pronunciation of Name Pronouns Short Title* Organization* Email* Assistant Email CC Email Cell Phone** We require direct cell phone numbers for all conference speakers. We will only use this for necessary onsite contact.Short Bio*Please provide a short bio of up to 100 words Headshot*Please upload your current headshot to be used on our website, programMax. file size: 20 MB.Speaker Role*Please choose your speaker role from list below.LIVE – Main StageLIVE – PanelistLIVE – HostLIVE – Executive Spotlight (pre-recorded)LIVE – Learning BurstLIVE – Executive Insights: That’s a Good QuestionVIRTUAL – Main StageVIRTUAL – HostVIRTUAL – Executive SpotlightVIRTUAL – Learning BurstPodcastTopics*Please select your top (3) topic preferences from the list below. Ways to Jumpstart Your Career How to Make a Career PivotChoice Corporate Culture and Employee Engagement Bringing Joy and Fun to the Workplace Workload Overload and Setting Boundaries Managing Challenging Employees/Difficult Personalities Leading Through Recession (or Change) Strategies to Effectively Lead Men Leading Millennials/Multigenerational Workplace Caregiving and Balance Navigating Ageism Succeeding Professionally When You Are in the Minority Business Acumen Skills (how to read a P&L, EBITDA, etc.) Financial Planning/Retirement Self-Care/Prioritizing Women’s Health Mindfulness Neurodiversity in the Workplace Negotiation for Flexibility Navigating a Hybrid Workplace Lift-Off: Developing a Business Plan, Finding Investors, Getting Your Company Off the Ground Recording Equipment Needs*In order to ensure the highest quality video, we require the following equipment be used during your session recording. Please select below which item(s) you would need for us to send to you. Ring light (or other professional quality lighting) Ethernet Cable (Speakers should be within 50ft of their router to use an ethernet cable during the recording) All of the above. None of the above. I have all these items. Mailing AddressPlease provide a mailing address where we can ship equipment for your session recording, if applicable. Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please provide (3) dates with PST times you would be available to dedicate a maximum of 60 minutes to record this session prior to December 15, 2023. For those with Executive Spotlight Roles to be played at LIVE Conference, please provide dates to record session prior to December 22th, 2023.* Note: While we can record up until this date, we strongly encourage all speakers to record as early as possible.What device will you be using for your recording? i.e. Computer, iPad, iPhone*This will determine the type of equipment we send to you. What type of laptop will you be working with?(i.e. Windows or Mac) – Please indicate model and year with your answer. What type of iPhone or smartphone do you have?(i.e. Android, iPhone 8, iPhone X, iPhone 11) Please indicate if you have a cable adapter that can connect your phone to your computer. EmailThis field is for validation purposes and should be left unchanged.
