Event date:


Event title/name:
(Include event theme and/or purpose.)

Event time(s):
(Indicate event starting and ending times.)

Books and/or book signing desired?
(Books can be purchased from Speaker upon advanced arrangement; signing can be hosted before or after event.  Indicate interest and number of books desired below.)
Yes
No

Event location and Facility:
(City/State; and indicate type of facility, e.g. hotel, company, training center, gymnasium, convention center; Please include room name and number in which the event will take place.)

Pre-event and on-site event contact name and phone number:

Contact Email Address:

Topic and length of presentation:
(Including designated question and answer period, if desired.)

Audience size and demographics:
(The number of attendees expected and brief statement of audience background and experience.  Example, the audience will consist of men and women who are professional association executives with a high level of experience.  If possible include age range, job responsibilities, male/female ratio, experience level, geographic representation.)

Goals and/or learning objectives for the presentation:

Rehearsal hours and location of speaker ready room, if any:

Room set-up (banquet, classroom, theater):
(Include the size of the stage and head table, if applicable; location of standing lecterns and number of seats.)

Program format:
(Will a moderator introduce the speaker and lead the questioning?  If so, please provide name and title.  What else will occur just before and just after the presentation?  Please attach event promotional materials and agenda/script and return with this questionnaire.)

Special guests:
(Indicate the names of any VIPs in attendance as well as the names and topics of any other speakers participating in the program.)

Related company/industry information:
(Pertinent background information and/or “hot” industry issues.)