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First Name:
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Last Name:
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Title:
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Company:
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Phone:
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Email Address:
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Snail Mail Address:
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How would classify your company?
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Affiliate/Publisher
Networks: Advertising/Affiliate/CPA
Agency/Consultant
Merchant /Advertiser
Vendor
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Have you attended an Affiliate Summit?
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Yes
No
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Speaker Bio (single paragraph, max. 1000 characters, including spaces).
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Session Title (max. 7 words)
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Session Description (max. 200 characters, including spaces)
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What format is your presentation?
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Debate
Roundtable
Panel
Solo presentation
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If your proposal is for a panel or debate, are you proposing that you moderate the session, or would you need a moderator assigned?
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I would be the moderator
I need a moderator
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If your proposal includes more than youself as a speaker, add the name, company, title, e-mail, and bio (max. 1000 characters per speaker, including spaces) of any other speakers below:
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If your proposal includes more than yourself as a speaker, are the others aware that you included them in your proposal?
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Yes
No
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Previous Speaking Experience (list last 3 speaking engagements)
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Attendees to this session should have the following experience level (please choose only one):
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Beginner
Intermediate
Advanced
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The bulk of the material covered in this session is for (please choose only one):
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Affiliates/Publishers
Merchants/Advertisers
Networks
Other
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Please include one additional keyword to describe the niche/vertical (if any) that your session mostly covers.
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What is your Twitter name?
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I confirm that the information above has been proofread and conforms to character and word limits. Additionally, I understand that this is the information that will be used on the site and conference program if my proposal is accepted.
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