Please print and complete the following and mail with your $35 check to:

Speak Freely

c/o Brodnicki Public Relations, Inc.
P.O. Box 172272
Arlington, TX 76003
(817) 572-1556

Date: _____________________________

Name:

Company:

Title:

Address:

City: State: Texas Zip:

Phone: Fax:

E-mail:

Title of Speech (keep it short!):

Brief description of speech:

Two to three “speaking” references with contact info: