Booking and Contracting Form (Ciciliani) Today's Date1212123456789101112141412345678910111213141516171819202122232425262728293031202420242024202520262027Workshop Partner Name(Required) First Last Workshop Partner Organizaton(Required)Workshop Partner Email(Required) Workshop Partner Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Workshop Course(Required) OPT: Three Part Treatment Plan (Level 1 course requirement) OPT: Assessment Plan Development (Level 1 course requirement) Other Workshop Instructor(Required) Tamara Ciciliani = $3000 per day What format is this workshop(Required) Virtual/Streaming (TalkTools will provide the virtual meeting platform) Virtual/Streaming (Workshop Partner will provide the virtual meeting platform) Live/In-Person Start Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2024202520262027End Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2024202520262027Total Number of Days(Required)Start Time(Required)each day Hours : Minutes AM PM AM/PM End Time(Required)each day Hours : Minutes AM PM AM/PM Are these times in YOUR timezone?(Required) The times are in my time zone The times are US Eastern (UTC-4) Workshop Venuename of workshop location, street, cityWorkshop Point of Contact (POC) during workshop(Required)VIRTUAL OR IN-PERSON: first name, last nameWorkshop POC email(Required)Estimated Number of Participants(Required)TalkTools expects the MAXIMUM number of participants for this workshop to be 60 (sixty) participants. For each participant exceeding this maximum number, the Workshop Partner will pay TalkTools® $40.00 per person for a 2-day workshop and $20.00 per person for a 1-day workshop. Total Honorarium/Speaker Fee for this workshopDeposit AmountDeposit is equal to 25% of the total speaker fee/honorarium for InstructorWill you need to purchase practicum (hands-on learning supplies) for this workshop(Required) Yes -- Workshop Partner will order practicum for each participant No -- Workshop Partner has the supplies and will assemble the practicum for each participant Practicum/Hands-On Learning Supplies List(Required)PLEASE REVIEW THE PRACTICUM LIST FOR THIS WORKSHOP - https://talktools.com/pages/live-workshop-practicum Workshop Partner has reviewed the practicum list Workshop Partner agrees to provide practicum for each participant Select the PRACTICUM SKU for this workshop if you are purchasing [3801] Three Part Treatment Plan for OPT [3803] OPT: Assessment and Program Plan Development Other Select the PRACTICUM PRICE this workshop if you are purchasing $5 (Three Part Treatment Plan for OPT) $15 (OPT: Assessment and Program Plan Development) Other Practicum price per participantEstimated Practicum Costsauto-calculatedInstructor Travel Terms(Required) Unless other terms have been agreed upon, Workshop Partner agrees that TalkTools will arrange airfare for Instructor based on estimates Workshop Partner has provided in this Agreement During the Instructor's stay for this Workshop, Workshop Partner agrees to pay and arrange for hotel accommodations, meals and transportation at reasonable rates TalkTools will invoice Workshop Partner for any incurred travel costs, as part of the final invoice (due to TalkTools within 30 days of the workshop dates) Estimated Total Workshop Costsauto-calculated
