"*" indicates required fields Step 1 of 3 33% Your InformationYour Name* First Last Your TitleEmail* Name of Organization Hosting Event*Organization Website Mobile Phone*Work Phone Event InformationWho are you Requesting?Select OneMr. Jason WilsonNägyid Chris NorrisEvent Type Keynote Speaker Motivational Speaker Guest Speaker Panelist Bible Study Presentation Seminar or Workshop Other Event Type Other (Please Specify)Event Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Event Location*Select a stateOutside the U.S.AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingSelect a CountryCanadaUnited KingdomNigeriaGhanaSouth AfricaKenyaJamaicaBahamasTrinidad and TobagoAustraliaUnited Arab EmiratesGermanyFranceOtherEvent Start Time Hours : Minutes AM PM AM/PM Event End Time Hours : Minutes AM PM AM/PM Event NamePurpose of Event / About the EventRole of the Speaker and Speaking ExpectationsTarget Audience (Check all that Apply) Adults Youth College Students Males Females Estimated Audience SizeOpen to the Public?Select OneYesNoTicketed Event?Select OneYesNoWill any portion of this Event be filmed, recorded, broadcast, or streamed?Select OneYesNoWill you provide us a copy for our marketing or merchandising use?Select OneYesNoDesired Speaking Topic:Select one of the topics below or suggest your own topic. Breaking Through Emotional Barriers Deadly Emotions Emotional Release and Rest for Men Emotional Stability for Adolescent Boys Other What is your speaker/panelist budget?What is your speaker/panelist budget?*Under $2,500$2,500 - $5,000$5,000 - $10,000$10,000 - $25,000$25,000+Prefer to discussDo you have a preferred or desired Topic? 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Podium Microphone Teleprompter Flip Chart Screen Computer Projector TV DVD Player How did you hear about Jason?* A friend or colleague referred me One of Jason's books The Cave of Adullam documentary Saw or heard him in the media (TV, podcast, radio) Social media Heard him speak at an event Google or web search Other Who can we thank for the referral?Which of Jason's books have you read? Cry Like a Man Battle Cry The Man the Moment Demands I haven't read one yet Select AllWhere did you see or hear him?The Breakfast ClubJoe RoganMan EnoughManTalksToday ShowOtherWhich platform?InstagramYouTubeFacebookX (Twitter)LinkedInOtherWhere did you see or hear him?Which event?Please shareAdditional InformationOptional Comments
