To help Jack prepare a program that is focused on your unique needs, please complete the following:

Your Name       



Phone Number              


Fax Number                 


Email Address  



What type of program are you interested in booking?   

What is the content of the program?   

Type of Event    


Other Event (describe below)

Event Date 

What is the purpose of the event?

Briefly describe the attendees.

How will the attendees be dressed?

Formal                 Business             Business Casual         Casual  

What are the "burning issues" of the attendees?

What happens right before I speak?

What will be done to follow-up the presentation?

How will this program complement the other things that are taking place in your organization?

What behaviors do you want to change or enhance?

What are three main points you would like to include in the presentation?

What else should Jack know that will help him better prepare his material?

Who are additional individuals that can be contacted to obtain valuable information?

Name        Title     Email    

Name        Title     Email      

Name        Title     Email      

Press "Submit" to send this information to Jack!