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Contact Information

Name (required)
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Degree/Professional Designation

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Street
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Company

Phone 1 (required)
Phone 2
Phone 3
Phone 4

Email (required)

Website

Current Occupation

1. My interest in the Speakers Academy program is:

 I want to apply

I am VERY enthused and would like to apply to the program. I understand that the program costs $1,995 for non-members and $1,395 for NSA/NC members. I have read and I understand the Speakers Academy Program information.
I agree that, once accepted, the program tuition is non-refundable.
 I'm considering it

I am enthused about the program, and I need to consider the following items before making my final decision:

2. What are your areas of speaking expertise?

3. Are you a member of NSA?

 I'm a current member of NSA
 I'm a salaried employee

How many times per year do you speak to groups of 15 or more?
 I'm not a salaried employee

How many times per year are you paid to speak?

4. Are you speaking professionally?

 Full-time — # years
 Part-time — # years
 Occasionally — # years
 Have never presented
Comments

5. What is your past speaking experience?

 Member of Toastmasters, Speaking Circles, etc.
 Attended other presentation skills programs:

 Spoken at Rotary, Lions, Soroptimist, other organizations (describe)


How many times in the last two years?

6. What types of speaking programs do you intend to present?

 Keynote
 Seminars
 Training
 I don't know yet
 Other:

7. On which topics do you speak?

8. Please share details from any book(s) published

9. Which of the following do you have or produce? (check all applicable boxes)

 Articles published on a regular basis
 Demo video
 One-sheet
 Other:

10. I can commit to the following, barring unforeseen events:

 Attend all eleven monthly meetings of Speakers Academy
 Do all homework assignments
 Attend all five NSA/NC general membership meetings
 Apply for membership of NSA when I meet the qualifications

11. Do you have any disability needs requiring special consideration?

12. Is there anything else you would like to share about yourself?

Please double-check all of your information above. Once you submit your application successfully, this form will be cleared. You will be emailed a copy of the accepted information.

Please contact Marit Fox at (650) 646-4220 or info@nsanc.org for more information.


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