Your Name
Your Phone
Your Email
Your Alternate's Name
Your Alternate's Phone
Introducer's Name
Introducer's Phone
Is there any publicity work Ben can do for you while he is at your event? Radio or televsion? Please let us know ahead of time, so we can arrange travel.
Who are the other speakers on the program?
Speaker
Speaker
Speaker
What speakers have you used in the past that have covered topics related to the material Ben will be presenting to you?
What did you like or dislike about their material? Without names if you would like, but do comment on material they used.
Name three main movers and shakers of your group that will be in Ben's audience. With your permission we would like to contact them for more research information on your group.
Mover & Shaker 1
Mover & Shaker 2
Mover & Shaker 3
What would make Ben's presentation really special for your group?

About The Audience
Number Attending
Percentage Male to Female
Are spouses coming?	No YesSome
Average age of the audience
Average annual income
Income Range
Educational Background
Major job responsibilities of audience
Does your audience have a specific problem or challenge?
Has your audience had a breakthrough?
What separates your high performance people from others?
Tell us about your industry? Include problems, challenges and break throughs.
Tell us about your organization? Include problems, challenges and break throughs.
Has your organization had a special event, merger or relocation?

Will Ben's presentation be taped?

Yes NoDon't Know

If you wish, Ben will make his educational materials available to your audience, so that they will may continue the learning process at home. There are two ways this can be arranged. Please check the one that is most appropriate for your group. A. Group purchased in advance for each attendee, at wholesale B. Materials made available at the back of the room after the presentation If you checked "B", please make sure that: Nothing will be on the program directly after Ben's presentation and that there will be a break for at least 20 minutes. A table will be made available for Ben to place his materials by the exit door. Someone from your group wil assist with sales

Travel Information
Venue Name
Address
Address
City
Province / State
Postal Code
Phone Number
Fax Number
Location at the site, room rates etc.?
Closest Airport
How will Ben be transported from the airport to your site?
Taxi Rental Car	Pick up person Pick up Person's Name Pick up Person's Phone
Comments