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Program Information Form

So we may better serve you, please take a moment to complete the form below.
Please note: All fields are required.
 
Basic Information  
Date(s) of presentation:
Name of event:
Organization:
   
Presentation Details  
Suggested topic(s):
Purpose/goal of the program:
Start time:   am  pm
End time:   am  pm
Other time-related details:
   
Audience size:
Audience members are:
   
Room Set-up and Handouts  
Basic set-up of the room:
Microphone available?: (wireless handheld preferred)
How will the participants be seated?  Round tables? Classroom? etc.
Will there be floor space to do activities? Yes No
Do you need title(s) for speaker's program(s)?  Yes No
    If yes, do you need written descriptions?  Yes No
 
Is it appropriate for speaker to set up a table for product sales? Yes No
Will the audience members have writing utensils? Yes No
Can a handout master copy be sent two weeks in advance for duplication? Yes No

Handouts are emailed in PDF format. To whom should they be emailed?
Name:
Email:
   
Contact information for Day of Event
Name:
Cell phone number:
   
Directions to the Event  
Location of event (building):
Room number:
Street address:
City:
State:
Zip:
Additional details:
   
Contact Information for Billing
First name:
Last name:
Organization/Your Title:
Address:
City:
State:
Zip:
Daytime phone:
Fax:
Email:
   
Billing Details  
Agreed upon charges: $
Mileage (if applicable, $0.55/mile): $

What other expenses are included in the payment or taken care of directly?
 
Have you received all of the paperwork from YourNextSpeaker necessary for payment?  Yes  No
 If "No," what is required?
Other Comments

Why did you choose YourNextSpeaker?
 
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