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Questionnaire
Once you have booked Tom for an event, please fill out this form and submit the information so that we can better customize our presentation for your audience.
* Required Field
Client Organization Information
*
Name of Organization:
*
Primary Location:
City:
State:
Choose State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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Nevada
New Hampshire
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New York
North Carolina
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
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Vermont
Virginia
Washington
West Virginia
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Zip:
Website Address:
Primary Contact Person Information
*
Full Name:
*
Phone:
Fax:
*
Email:
Topic Information
What is your chosen topic?:
How is this particularly relevant to your organization?:
Please select topic relevance here:
Extremely relevant
Very relevant
Somewhat relevant
Not applicable
What would the audience most like to learn about this topic?:
Event Information
Name of Event:
Type of Event:
Location of the Event:
Timeslot for Tom’s Presentation:
What is immediately before and after Tom’s Presentation?:
What opportunties exist for networking before or after the presentation?:
Audience Information
Expected Size:
Please select an approximate range
10 to 50
50 to 100
100 to 500
500 to 1000
1000 or more
Brief Description of Typical Audience Members:
* Three Audience Members to Interview in Advance
Several likely audience members will be contacted for a 10- to 15-minute interview about their interests in and expectations of the topic.
Contact Name #1
Name:
Phone:
Email:
Contact Name #2
Name:
Phone:
Email:
Contact Name #3
Name:
Phone:
Email:
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