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Speaker - Educator Listing Form

  • Your Name *
    Title
    First
    Last
    Suffix
     
    Please provide you name as you would like it listed.
  • Business Name
    Please provide the business name as you would like it listed. If the only name you want listed is your name, leave this field blank.
  • Address *
    Street Address
    Address Line 2
    City
    State / Province / Region
    Zip / Postal Code
    Country
     
    Please provide the address you would like listed.
  • Business Phone *
    (###)
    -
    ###
    -
    ####
     
    Please provide your telephone number as you would like it listed.
  • Fax Number
    (###)
    -
    ###
    -
    ####
     
    Please provide a fax number to be listed.
  • Cell Number
    (###)
    -
    ###
    -
    ####
     
    Please provide a cell number if you would like one listed.
  • Business Email *
    Please provide the email address to be listed.
  • Personal Email *
    Please provide the email address we should use to contact you. This may be the same as the business email.
  • Hourly Rate
    $
    Dollars
    .
    Cents
     
    Please provide your hourly rate, if any
  • Available Services *
    Please provide a general description of your available services. This information will be copied into your MRU listing, so please make sure everything as EXACTLY as you want it to appear.
  • Consent *
    Approved
    By checking the box, you agree to allow My Rental Units, LLC to post the information you have provided and agree to hold My Rental Units, LLC harmless and agree to indemnify them from any and all damages or losses arising out of said listing.

    You confirm the information you have provided is accurate and true.
  • Electronic Signature *
    Please type your name to act as an electronic signature. You represent you have authority to submit this information.
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