Speakers Academy Application Form1 About You2 Application QuestionsContact InformationYour basic name and contact information (address, phone numbers, email address).Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Cell Phone*Work PhoneHome PhoneProfessional InformationYour website, social networks links, and current job information.LinkedIn Profile NameWebsite 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?*YesNoPlease describe your last 3 presentations:* Your MembershipsAre you a member of the NSA?*YesNoHow 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.OtherPlease specify:Speaking ExperienceWhat 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 yetWhat 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 OtherPlease specify your other unpaid speaking experiences.*How many total paid and unpaid speeches/presentations have you done in the past 12 months?Paid speeking presentationsUnpaid speeking presentationsWhat is your goal regarding your speaking career?* Full-time paid professional speaker Part-time paid professional speaker Occasional paid professional speaker OtherPlease specify your other goalPlease 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?*YesNoWhy 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)CAPTCHANameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.