Questionnaire

Please take a moment to complete this survey. Your answers will help me to tailor the presentation to your group.

If you would prefer to fax in your form, fill out this printable PDF Fax Back Form and fax it to us at
303-932-0990.

Your Details
Name:
Email:
Organization:
Meeting Details
Type:
Theme:
Purpose:
Attire:
Event Site Details
Location:
Address:
Telephone:
Contact:
PH:
In case of an emergency who can I contact on site of the event or within 24 hours of the event?:	Name: Phone a: Phone b: Phone c:
Presentation Details
a. Date:
Setup Time:
Start Time:
Duration:	Hours Minutes
b. Date:
Setup Time:
Start Time:
Duration:	Hours Minutes
c. Date:
Setup Time:
Start Time:
Duration:	Hours Minutes
**Setup time for my programs are no less than 15 minutes. This may be done just prior to my event if you have a break scheduled or it may be done earlier in the day and the prop tables brought to the front of the room just prior to my event. Contact Tim for more information or questions 1-800-865-9939 ext. 1
Travel Details
Closest airport to site:
Recommended transportation from airport:	Company: Phone #:
Estimated travel time from airport to site:	Hours Minutes
Special Directions:
Audience Details
Estimated number of people each program:	a. b. c.
Age Group:	to years old (approx.)
Will children be attending?
Gender Ratio:	Male: % Female: %
Who will attend?:
Briefly, what is the nature of the work performed by the group?:
Employed by:
Please list a few job situations or duties that can cause stress to my audience as they do their work:	a. b. c.
What are some of the things that the public - customers - coworkers - say or do that may irritate or cause stress at work?:	a. b. c.
Are there any specific topics you would like me to address or avoid in my seminar?:
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