Contact Information
Your E-Mail Address: (required)
Complete Name of Facility or Group:
Website Address:
Contact Person and Title:
Address:
City:
State:
Zip Code:
Best time to reach:
Phone Numbers (work):
Fax:
Cell:
Evening or Emergency Contact:
Program Information
Dr. Douglas' Program #1 Topic/Title:
Date:
Time:
Break Times(if applicable):
Dr. Douglas' Program #2 Topic/Title:
Date:
Time:
Break Times(if applicable):
Meeting Information
Meeting Location:
Meeting Address:
Meeting City:
Meeting State:
Meeting Zip Code:
Transportation Information
Closest Airport:
Number of miles from airport to meeting site and hotel:
Will someone be meeting me? If so, please provide the name, location and time:
Specific directions to meeting location and contact person at the meeting site:
What form of transportation will be provided to the meeting site?
Hotel Information
Hotel Name(if applicable):
Hotel Address(if applicable):
Hotel City(if applicable):
Hotel State(if applicable):
Hotel Zip Code(if applicable):
Hotel Phone Number(if applicable):
Will the hotel be directly billed to you (client)?
Meeting Information
What form of ground transportation will be used to and from the hotel and airport?
What is the conference theme?
Who will be introducing me? (Please provide name, title, and e-mail address):
What are your goals and objectives for my portion of your program?
How will you know if I am successful? (Please define a target)
How can I assist you in meeting these objectives? What 2 or 3 points would you like made?
Would you like worksheet and/or bulletin board piece originals to copy?
Page Number Limit:
Preferred Format:
Will you require CEU information?
CEU information due date:
Who will be attending this presentation? (job titles - age range - gender mix - deparments)
How large will the group be?
Describe the room and stage/seating setup for the meeting:
Who will be the A.V. contact person?
What is the A.V. contact person's number?
When is the A.V. setup and sound check?
What is the general attitude of the group?
Are there any areas of discussion you prefer be avoided or sensitive issues of which I should be aware?
What is the mission of your company or group?
What are the current stressors or challenges you are facing?
What is special or unique about the people in this audience (e.g., languages, disabilities)?
What is happening before and after my presentation:
Please list other speakers, their topics, and their time slots:
Product Information
Would you like me to have products available for sale?
How would you like me to handle the sale of products?
Buzzwords:
Pet Peeves:
Inside Jokes:
Audience members you would like mentioned:
Names and phone numbers of anyone you'd like me to talk with for input:
Is there anything else I can do to ensure the success of your meeting?
Please send copies of program brochures, agendas, or other promotional materials so my presentation is consistent with your advertising. I'd also appreciate any newsletters, articles or information on your group/facility you feel would be helpful in my presentation.
Information can be sent
to seminars@drdonnadouglas.com
SPEAKING