1.   Company/Organization:

2.   Address:    City   State   ZIP

3.   Contact Person:    Title: 

4.   Phone ()    Fax: ()   Cell: ( )

5.   E-mail address:  Website: 

6.   Day & Date of Event:    Time:    AM   PM

7.   Start Time for our presentation:    End Time for our presentation: 

8.   Location of Event with directions (Please include name of facility): 

9.   Is this a Workshop/Seminar   Keynote Speech   Breakout Expected Attendance

10.  Average Age:    Attire:   Educational Background: 

11.  What is your Occasion? 

      Currently, what is your biggest challenge? 

      Do you expect any major changes in the next year?  Explain.

      What three (3) main points would you like to get across in our presentation?

      A.  
     
      B.  
     
      C.  

      What are your desired results for our presentation?

12.  What other information can you give us to make your program special?

13.  My audiovisual requirements are: Overhead projector & screen  wireless mic, lavalier

14.  Are there other speaker(s) on your program?   Before or after me? 

       On What Topic? 

15.  Who will introduce me?   I have an introducer Yes  No

16.  Do we have your permission to sell our resources, books, tapes, videos, etc? 

17.  What is your company/organization’s mission statement? (Use additional paper if needed)