Speakers Academy Application Form 1 About You 2 Application Questions Contact Information Your basic name and contact information (address, phone numbers, email address). Name* First Last Address* Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific State ZIP Code Email Cell Phone* Work Phone Home Phone Professional Information Your website, social networks links, and current job information. LinkedIn Profile Name Website Current Occupation* Describe your job at present.What do you do? Who do you do it for? Have you met the pre-requisite of a minimum of 3 presentations over the past 12 months?* Yes No Please describe your last 3 presentations:* Your Memberships Are you a member of the NSA?* Yes No How many years have you been a member?* My interest in the Speaker’s Academy is:* I would like to apply to the Academy. I have read and understand the Academy’s program information. I am interested in the Academy, but need to consider the following items/issues before making a final decision. Other Please specify: Speaking Experience What topics you speak on, who your audience is, what your specific paid/unpaid experience is, etc. What type of speaking do you do, or want to do?* Keynotes Seminars Training Coaching Consulting Don’t know yet What topics do you speak on (areas of expertise) or what topics do you want to speak on?* Who is your primary audience? What are your unpaid speaking experiences? I am a member of Toastmasters I am a member of ATD I am a member of SHRM I have spoken to Lions, Rotary, or similar organizations Other Please specify your other unpaid speaking experiences.* How many total paid and unpaid speeches/presentations have you done in the past 12 months? Paid speeking presentations Unpaid speeking presentations What is your goal regarding your speaking career?* Full-time paid professional speaker Part-time paid professional speaker Occasional paid professional speaker Other Please specify your other goal Please describe any books you have published. Do you have talents, strengths or skills you would like to share with us/others in the Academy? Have you owned a business before?* Yes No Why do you think the Academy is right for you at this point in your life?* What's your goal? Any other information or accommodations needed you would like us to know about? Choose Your Academy Session Dates* Fall Start (August – June) Spring Start (February – January) CAPTCHA NameThis field is for validation purposes and should be left unchanged.