REQUEST DR. ROC Name Email Address Message School/Organization Name Phone Number Target Date Expected Attendance What type of presentation would you like? Check all that apply What type of presentation would you like? Check all that apply Keynote Speech Conference Workshop Professional Development Presentation to Students Who referred you Please list the event where you met Dr. Roc I'm interested in: I'm interested in: Learning More About Dr. Roc Registering for a Webinar Series Attending a Dr. Roc Seminar Purchasing Dr. Roc's Courses or Resources 9 + 3 = SUBMIT DR. ROC IN ACTION Click Image to View Larger