Answer Our Survey When You Join Our Speaker’s Bureau Step 1 of 2 50% Speaker’s Name First Last Speaker’s Email Date of Event Date Format: MM slash DD slash YYYY Location of EventWas the Facility Conducive?Name of Event Host/Contact Person First Last Was the Host/Contact Person Helpful in Making You Comfortable?How Many Attendees?Was the Audience Engaged?What Challenges Did You Face?What Suggestions Do You Have After this Experience?All applicants for the District 10 Speakers Bureau are expected to be excellent representatives of the speaking skills learned in Toastmasters. Therefore, all applicants will undergo a thorough vetting process before acceptance into the Bureau. Part of the process consists of having each applicant deliver one speech to one of District 10's Advanced Clubs for review.Do you agree to the conditions and terms stated above?*Yes, I agreeNo, I do not agree to the conditions and terms aboveExplain your reasons for not agreeing with the stated terms and conditions. Please complete the form below as completely as possible. All items with a red asterisk * are required fields. Remember, at the present time you cannot edit the information after submitting, but you will be able to do so at a later date. Part 1: Your Personal Information Your Full Name* First Name Last Name Suffix Primary Phone Number*Area Code Phone Number Alternate/Back Up Phone NumberArea Code Phone Number Your Mailing Address* Street Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email Address* What Year Did You Join Toastmasters?*Average Number of Speeches Delivered Annually to Toastmasters Audiences?*Write a short biographical statement, no more than 150 words that will be read by people searching for a speaker.* Part 2: Your Speaking Topics Provide your 3 speech titles including your target audience(REQUIRED) Speech Title #1:*Speech #1 Summary of Content:*Speech #1 Target Audience:*Speech #1 Length(s)*(OPTIONAL) Speech #2: Title of SpeechSpeech #2: Summary of Content:Speech #2 Target AudienceSpeech #2 Length(s)(OPTIONAL) Speech #3: Title of SpeechSpeech #3: Summary of Content:Speech #3 Target AudienceSpeech #3 Length(s)Do you have other presentations outside of those three?YesNoWhat times are you available to speak? Evening or Daytime?EveningDaytimeSkills in Addition to Speaking (e.g.: Master of Ceremonies, Facilitator, Corporate Trainer)Please State Your Availability for Presentations. Many business audiences require speakers to be available during business hours, but there are many evening opportunities as well.*Part 3: Headshot submissionPicture: Please use the "browse" button below to upload a picture of yourself for use on the Speakers Bureau website.*Video: If you have any published (on the internet) videos of you speaking, please provide the link or links. Please separate multiple links so they are easily recognizable. These could be links to YouTube, Vimeo, or any other location where you post videos. If you have no videos available, please enter the words "No Videos".*Website: If you have your own website, please enter the address below:Final Step Before Submitting Your Application Please review all your answers for completeness and verify you have completed any required fields. When you are satisfied with your application, click the red button below to submit your information. You will receive a confirmation email containing all the data you submitted as a record of your application. Thank you for taking the time to complete this application for the District 10 Speaker's Bureau! (There may be a delay after pressing the Submit button while your picture is uploaded. Wait for the confirmation screen before closing your browser.) This iframe contains the logic required to handle Ajax powered Gravity Forms.