Your Name:
Your Title:
~

Your Organization:
Organization Website:
Address:
City:
State: Select Your State Here ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW ENGLAND NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WASHINGTON, DC WEST VIRGINIA WISCONSIN WYOMING OTHER -CANADA OTHER -INTERNATIONAL Zip:
~

Office Phone:
Office Fax:
Alt. Phone:
~

Supervisor's Name:
Supervisor's Title:
~

2. When is the event taking place ?

Date of Event:
Times of Event: Select Here Morning Afternoon Evening All Day Multi-Day

3. How many speakers will you be hiring for this event ?

Select Here One Two Or More

4. What is the budget range for the speaker at this event ?

Select Here $ 1000 to 2000 $ 2000 to 3500 $ 3500 to 5000 $ 5000 to 7500 $ 7500 to 10000 $ 10000 to 15000 $ 15000 to 25000 $ 25000 to 50000 $ 50000 to 75000 $ 75000 to 100000 $ 100000 & Up To Be Determined

Actual Budget:

5. Did you plan to cover the Speaker's travel expenses separately ?
(The speaker's travel expenses normally include airfare and hotel.)

Select Here Yes No

6. Who will the speaker be addressing ?

Name of Event:
This Event: Select Here is a One Time Event is an Established Annual Event will be an Annual Event might become an Annual Event Other
Size of Group: Select Here Under 50 50 to 100 101 to 200 201 to 500 501 to 1,000 1,001 to 2,000 2,001 to 5,000 Over 5,000

7. How much time is reserved for the presentation ?

Select Here Under 30 Minutes 30 to 60 Minutes 60 to 90 Minutes 1 1/2 to 3 Hours 3 to 6 Hours More Than One Day

8. What topics do you want presented ?

Primary Topic: Select Here To Be Determined OTHER- See Comments Below Achievement Adventure Advertising Aging / Retirement Alcoholism / Drug Recovery Assertiveness Athletes / Sports Authorship Broadcast Personalities Business Change Character Portrayals Children?s Issues Christian Issues Comedians Communications Computers Conflict Management Consultants / Consulting Creative Thinking / Innovation Current Events Customer Service Diversity E-Commerce Economics Entertainment Entrepreneurship Ethic & Values Family Financial Issues- Corporate Financial Issues- Personal Fitness Gender Issues Goal Setting Government / Politics Health, Fitness & Nutrition Human Relations Human Resources Humor Innovation Inspiration International Issues Internet Image Development Jewish Issues Legal Issues / Law Leadership Magic Management Marketing Media Medical Men?s Issues Mentoring Motivation National Issues Negotiation Networking Nutrition Organizational Skills OTHER- See Comments Below Patriotic Performance Improvement Personal Development Politics Presentation Skills Problem Solving Productivity Psychology Public Relations Real Estate Training Relationships Religious- Christian Religious- Jewish Retail Issues Safety Issues Sales Management Sales Skills Self-Esteem Self-Management Seniors / Retirement Security Social Issues Spouse Programs Spiritual Growth Strategic Planning Stress / Burnout Success Survivors Team Building Technology Time Management TQM (Total Quality Management) Women?s Issues Writing Skills Youth Issues To Be Determined

Secondary Topic: Select Here To Be Determined OTHER- See Comments Below Achievement Adventure Advertising Aging / Retirement Alcoholism / Drug Recovery Assertiveness Athletes / Sports Authorship Broadcast Personalities Business Change Character Portrayals Children?s Issues Christian Issues Comedians Communications Computers Conflict Management Consultants / Consulting Creative Thinking / Innovation Current Events Customer Service Diversity E-Commerce Economics Entertainment Entrepreneurship Ethic & Values Family Financial Issues- Corporate Financial Issues- Personal Fitness Gender Issues Goal Setting Government / Politics Health, Fitness & Nutrition Human Relations Human Resources Humor Innovation Inspiration International Issues Internet Image Development Jewish Issues Legal Issues / Law Leadership Magic Management Marketing Media Medical Men?s Issues Mentoring Motivation National Issues Negotiation Networking Nutrition Organizational Skills OTHER- See Comments Below Patriotic Performance Improvement Personal Development Politics Presentation Skills Problem Solving Productivity Psychology Public Relations Real Estate Training Relationships Religious- Christian Religious- Jewish Retail Issues Safety Issues Sales Management Sales Skills Self-Esteem Self-Management Seniors / Retirement Security Social Issues Spouse Programs Spiritual Growth Strategic Planning Stress / Burnout Success Survivors Team Building Technology Time Management TQM (Total Quality Management) Women?s Issues Writing Skills Youth Issues To Be Determined

Tell Us More About Your Topic(s):

9. Where is the event taking place ?

Event Location:
Event Address:
City:
* State: Select Here ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW ENGLAND NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WASHINGTON, DC WEST VIRGINIA WISCONSIN WYOMING OTHER -CANADA OTHER -INTERNATIONAL * Zip:
Location Phone:

10. Do you have any preference about the Speaker's gender ?

Select Here Both are fine We prefer a man We prefer a woman We require a man We require a woman

11. What is the nearest Major Airport to the Event Location ?

Name of Airport:

12. Is there anything else you want tell us ?

How did you discover our Speakers Bureau website?

* Please, include your e-mail address.

E-mail Address:

Note: This form will be sent after you click on "Submit Form".
Next, click "OK" to send us your e-mail address,
and then click "Send" to complete your e-mail.

Submit Form Clear