Speaker Application

To be considered for acceptance as a speaker for LIFE Vision Seminars, please complete and return the following:

  1. Speaker Application Form (this form) - Online
  2. Speaker Biography Form - Online
  3. Presentation Proposal Form - Online
  4. Current Curriculum Vitae
  5. YouTube and/or Website Link
  6. Three (3) References (Contact Name, Organization, Phone Number)

Personal Data

Last, First, Middle, Suffix

Are you eligible to work in the United States?



Address 1 Address 2
City State ZIP


Address 1 Address 2
City State ZIP

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:


High School Graduation YR
Address City State Zip

List all colleges, universities, and chiropractic institutions attended

Name of Institution
(In Chronological Order)
(City and State)
Year of


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.

State or Province Type of License/Certificate License Number Date Obtained


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:

e: Gilles.Lamarche@LIFE.edu

f: 770.429.4819

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.