Contact Information

Proposed Time: *

Proposed Travel Dates:
 departure from South Florida

 return to South Florida

Generally departs from South Florida: West Palm Beach, Fort Lauderdale, Miami or Boca Raton Airports. Sometimes Jim's travel schedule dictates other points of departure. Generally Jim flies first class and requires a hotel room with high speed Internet access.

Nature of Presentation: *

Please select all that apply
 Opening Keynote
 Closing Keynote
 Breakfast Speaker
 Luncheon Speaker
 Dinner Speaker
 After Dinner Speaker
 Present a Workshop
 Moderate a Panel
 Participate in a Panel
 Other, please explain:

Topic of Presentation: *
We would like Jim to address the subject of ...

 Jim can use a presentation he has given elsewhere.
 Jim can use a presentation he has given previously, but not one presented at
 We would like a presentation specifically for our event.

Estimated Audience Size:

Nature of the Audience: *
Please describe attendees' job categories, male/female ratio and other relevant information...

Audio/Visual Requiremens & Handouts:
What would you like Jim to bring?
 Nothing - AV & Handouts would be inappropriate.
 Major AV - video, music, multi-screen presentation, etc.
 A nice PowerPoint with appropriate photos & illustrations.
 A simple, all-text PowerPoint.
 Use on-site overhead projectors or easels with paper/markers.
 Handouts to enhance take home value.

Is the organization sponsoring this event a 501(C)3 (charitable) organization?
select oneYesNo

What is the venue for the presentation: *

City, State, or Province of the Venue: *

Country of the Venue:

Proposed Compensation or Honorarium:

Coordination: Who is the individual we should work with regarding arranging for this presentation?

Name: *

Organization: *

E-Mail: *

Telephone: *

Fax:

Address: *

City, State, or Province: *

Country:

Zip or postal code:

Additional Comments:
Please feel free to tell us anything we should know about your organization, this occasion, etc.

Code *