First Name:
Last Name:
Organization:
Email:
Phone:
Example: (123) 456-7890
Program Date(s):
Type of event and specific purpose:
 
Please provide a general description of the audience:
 
What is the total number of attendees?
Is there a theme for the meeting?
What is your organization's mission statement or company philosophy?
 
Please provide the specific objectives you desire from my presentation:
 
Are there any professional challenges facing the individuals in the audience, or your company's industry?
 
Are there any difficulties currently being faced by your industry?
 
Describe the most significant changes this group has experienced during the last twelve months:
 
What are some of the accomplishments this audience has attained?
 
Please list other speakers presenting at this event:
 
Please list previous speakers at your company's events:
 
What takes place immediately before and after my program (meal, break, another session/speaker)?
 
If this speaking engagement is for a conference, please note the dates/times will the conference begin and end:
 
Please note the times my presentation should begin and end:
 
Please provide the name and title of the individual that will be introducing me (introduction supplied):
 
Meeting Location:  
Address:
City:
State:
Zip:
Phone:
Example: (123) 456-7890
Distance from Airport:
How will I be transported from the airport to meeting site/hotel?
 
Name of hotel in which I will be staying?
Address:
City:
State:
Zip:
Phone:
Example: (123) 456-7890
Will this hotel room be billed to your master account?
 
If yes, please provide the Confirmation Number:
 
Whom should I contact upon my arrival at the meeting site/hotel?
Name:
Phone:
Example: (123) 456-7890
Please provide an Emergency Contact:
Name:
Phone:
Example: (123) 456-7890
What is the appropriate attire?
Is there additional information that I should know?
 
Please let us know how you heard about Jim:
 
Other:
   

 

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