To be considered for acceptance as a speaker for LIFE Vision Seminars, please complete and return the following:
Last, First, Middle, Suffix
Are you eligible to work in the United States?
If you have someone you would like us to contact to schedule your presentations and appearances, please give his/her name and contact information in the field below:
List all colleges, universities, and chiropractic institutions attended
Please list all states, provinces or foreign countries in which you hold a chiropractic license(s), basic science certificate(s), or other professional certificates or diplomas.
List the subjects on which you feel qualified to speak:
Have you ever been convicted of, received deferred adjudication for, or plead no contest (nolo contendere) to any crime, other than a misdemeanor traffic offense? YesNo
If you have any published materials (e.g. books, videos, DVDs) or press kits, feel free to include these with your application.
Return entire speaker packet via fax or e-mail to:
Books etc. can be mailed to : Life University, c/o Dr. Gilles LaMarche, 1269 Barclay Circle, Marietta, GA 30060
I certify that the information submitted on this application is true and complete to the best of my knowledge and belief, and I understand that falsification of any of the information contained herein shall be grounds for disqualification from further consideration or for my immediate dismissal. I authorize LIFE Vision Seminars to conduct an investigation of my background and to verify my license(s) to confirm the information I have provided. I also understand that if I am accepted as a speaker for LIFE Vision Seminars, my submission of this online form authorizes LIFE Vision Seminars to use my name and/or picture in marketing materials and any and all publications.