Back Hope Affiliate Contact

Back Hope Affiliate Information

Please complete the form below if you have questions about promoting the Back Hope Telesummit. Based on your availability, we'll contact you to answer any questions or determine how to best make this event work for you.
Full Name *

First Name Last Name
Who should we communicate with?

If you would like us to communicate with a staff member or associate, please provide that person's name here.
Contact Person

First Name Last Name
E-mail *
Phone Number *

Area Code Phone Number
Skype ID
Your Market or Interest in the event
Ways you can promote the Back Hope Telesummit (check all that apply) *

Email List Facebook Clients Radio Internet Radio Other (describe below)
Other
Estimated Audience Reach (realistic)
Website
Any Questions or Comments for us
Best Time to Discuss this with you

Please choose two times that you are available to discuss the event and we'll contact you at one of them unless we are already booked. We will reply confirming the time as soon as possible. Please note we are in the Central US Time Zone, -6 GMT
Your Time Zone *
1st Preference for contact

Month Day Year
at
Hour Minutes AM/PM Option
2nd Preference for contact

Month Day Year
at
Hour Minutes AM/PM Option
You can also provide us with a general time to contact you if you don't want to set a specific time.
Time of Day

Weekday AM Weekday PM Weekday Evening Weekends
Should be Empty:

Back Hope Affiliate Information