Request Form

First Name (required)

Last Name (required)

Name of Company or Event (required)

Phone (required)

Email (required)

Fax (required)

Speaking Topic (required)

Date of Event (Month)



Specify Time of Event (e.g. 7:00pm) (required)

Event Location Name

City, State/Province



Length of Presentation Needed?

Multiple Presentations Needed?

Audience Size

Describe the audience. What do they do?

What are their challenges?

What do they want to learn/take away from this session?

A/V equipment available?

Will you film the event? (if so, request a copy)

Internet access available?

Vendor table available for books/products sales?

Interested in purchasing books for audience?

What is your budget for this presentation?

What are the guidelines for travel budget and arrangements? Should I book the travel or will your company handle that?

Additional Infomation