ON-LINE SPEAKER REQUEST FORM
Instructions:
Please print and Mail to:
Pinc Bubble Speaker
742 Montana Road NW
Atlanta, GA 30327
Attn: Speaker Request
Contact Person:
Phone:
E-mail address:
Company/Association:
Title:
Address:
City: State/Prov: Zip:
FAX:
Date of Event (or potential date): Time (Speaker is Needed:)
Name of Event:
Purpose of Event:
Event Location:
City: State/Prov:
Hotel/Event Facility:
Speaker Format(s):
Opening SpeakerKeynote Training Workshop
Breakout Seminar Closing Speaker
Length of Speech:
# of Speakers Needed:
Speech Topics Needed:
Speaker(s) you may already be interested in (a specific speaker that you would like us to locate):
Please send promotional kits for appropriate speakers
# Of Attendees:
Description of audience (sales reps, Board of Directors, etc.):
What do you want attendees to get from the presentation:
What budget range do you want to stay within:
What is your role in planning the event:
Please Choose One
Decision
Maker
Event Planner
Committee
Member
Information Gatherer
Interested Party
Other
Please tell us how you found us:
Please Choose One
Yahoo
Ask.com
AOL
All The Web
MSN.com
Banner Ad
Friend or Colleague
Other
Deadline:
Additional comments: