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Startpress Enter Date Prefix Suffix Name First Last Last Email Phone Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Please indicate the flat rate US travel allowance for air and ground travel $1,000$1,000 – $2500 (Standard)$2500-$5000 Are you looking for a specific gender, age, race or other specific personal demographics? Are you looking for a celebrity or non-celebrity speaker? Celebrity Non-Celebrity Would you prefer a published author? No Yes Would you prefer a speaker from industry, or academics? Industry Academics On a scale from 1 to 5 how important is entertainment? 1 On a scale from 1 to 5 how important is industry specific, content? 1 On a scale from 1 to 5 how important is practical, versus research knowledge? 1 Please select the type of speaker you are looking for? If you’re looking for multiple speakers please select all that apply. Opening Keynote Speaker Closing Keynote Speaker Conference Speaker Panelist Moderator Host (MC) In the following groups, please select ALL areas of expertise connected to the topic that is most relevant for your event. Enterprise Culture Key Trends (Select all that apply.) Talent Attraction/Retention CX Driver Return on Human Capital (RHC) Innovation HCP and Stakeholder Happiness Consumer Experience Key Trends (CX) (Select all that apply.) Patient Satisfaction Satisfaction Scores Safety, Quality, and Compliance HCP Satisfaction Enterprise Growth Sociological Key Trends (Select all that apply.) Healthcare Equity Personalization Healthcare Access Caregiver Support Diversity Management Key Trends (Select all that apply.) Chaotic Innovation Stakeholder Happiness Value Based Care Economic and Clinical Models Enterprise Excellence ACA 2.0 Economic Key Trends (Select all that apply.) Consumerization Transparency Utilization Sustainability Value Shift Technology Key Trends (Select all that apply.) Connection Architecture Decentralization Wearable/implantable Emerging Technologies Digitalization Value Key Trends (Select all that apply.) Prevention vs Intervention Alternative Pathways Experiential Value Low Cost, Big Value Data Analytics Clinical Key Trends (Select all that apply.) Anticipatory Genomics Continuous Patient Monitoring Consumerization of Care Emerging Drug/devices HCP Burn Out What is the primary objective of your event? Please provide us with any additional information to help us find you the perfect speaker. Important Notice Keynoteology® has a simple business model. We leverage our proprietary resources to find the perfect Speaker for our members. Therefore, you agree that if you use any of the Speakers that we recommend, that you will book them through us. Remember our fees are paid by the speaker, not you. By selecting Yes, you agree that if you choose to book one of our speakers that we have recommended that you, will book them through us. I agree not to circumvent Keynoteology® in the booking of Speakers recommended to by Keynoteology® * No Yes If you are human, leave this field blank. NextSubmit Use Shift+Tab to go back Don’t have the time to fill out the form? Give us a call: 530-782-2625
