Please fill out the form below with as much information as possible. We will contact your associate immediately to help them with their speaker needs.

This form has five quick parts:

• Specific Event Information
  
• Describe The Ideal Speaker For Your Associate
  
• Your Contact Information
  
• Your Associate's Contact Information
  
• Commission Payment Information
  

You only need to fill out as much information as you know in the first two sections (can leave many fields blank).

Is your associate looking for a keynote speaker or trainer now? Yes No

What is your affiliation to associate?

Is there a specific conference or meeting scheduled, if so when?

City & site of event:

What type of business is your associate's organization?

Who is the audience?

How many speakers is your associate looking for?

Describe The Ideal Speaker(s)
(please provide as many details as possible - if known)

Who are some of the speakers who have presented before the organization in the past? Did you present before your associate's organization?

Please list any speaker(s) your associate is already interested in booking or that you think might be ideal for the presentation (any colleagues?):

What is the budget range for their ideal speaker(s)? (if known): $2.5k - 5.0k $5.0k - 10.0k $10.0k - 15.0k $15.0k - 20.0k $20.0k - 25.0k $25.0k - 35.0k $35.0k - 50.0k $50.0k+

What effect/ impact do they want the speaker to have on their audience?
Examples: Educational, Inspirational, Entertaining, etc.

What qualities are they looking for in a speaker?

Informational Humorous Tools & Techniques Entertaining

Current Event Lecturing Case Study

What is most important about the speaker they need?

• Who they are
• What they do or have done
• The information they impart
• Their presentation style
• Their educational content
• Their "star" quality
• Their personal achievements
  

What qualities are they not looking for in a speaker?

What is the theme of their event and describe the issues related to their event that the speaker will need to address.

Please list any additional objectives, needs or comments:

Your Contact Information:

First Name:		Last Name:
Company:		Title:
Address:		City:
State:		Zip Code:
Phone:		Fax:
Website URL:
E-mail:

Your Associate's Contact Information:

First Name:		Last Name:
Company:		Title:
Address:		City:
State:		Zip Code:
Phone:		Fax:
Website URL:
E-mail:

Commission Payment Information:
Would you like your commission to go to:
your address above, or to a charity donated in your name?
If a charity, please provide the information below:

Charity Name:
Address:		City:
State:		Zip:
Phone:
Charity Web Site: