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NSA South Africa
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Powerful Presentations Alliance

In order for me to effectively manage your request, please complete the following information as best as you can.
Your Personal and Contact Information
Title
Your First name
Your Surname
Your Position in the Business
Your Telephone number  
Your Fax number
  
Your Cell number
Your e-Mail address
Best Time for me to Reach You Hour Time Zone Eg: SA, Europe etc
Your Business / Organisation Information
Business Name
Nature of Business / Products etc.
Business Physical address
 
 
 
 
Business Postal address
 
 
 
Business e-Mail address
Business Web Site address
Business Telephone number
  
Business Fax number
  
Your Event Information
What is this Occasion / Event?
If Other, please specify
What is the THEME of the event?
What Other Event/s have you had in the past year?
What are the dates for this event?
Speaking Assignment Date and Time Information
Date - Speaking Assignment Required
 (Please use correct Format - 01 January 2008)
Time of Day - Speaking Assignment Required
Duration of Speaking Assignment
Your Venue Information
Country of your Event
Region / Province of your Event
City / Town of your Event
Nearest Airport
Actual Venue of your Event
Is there accommodation available at this event (if applicable)
Your Audience Information
Approx. Size of Audience
Approx. Audience Demographics percent male
percent female
Company Mix Percentage percent company staff
percent customers
percent open to public
Management / Staff Mix percent management
percent staff
percent other
Is this a Specialist Group - If so, please give details
Please list 3 items you believe I should know before addressing this group?
What are YOUR goals for this Audience?
Any Other Information that may help me to make this presentation relevant to
this audience?
Your Speaker Requirements & Information
What would you like my to achieve
(Choose more than one if necessary)		  
Deliver a Keynote Address
Deliver a Breakaway or Secondary Address
Conduct an In-House/Tailored Training Session(s)
Deliver a Conference Presentation
MC a Function
Facilitate a Workshop / Brainstorm Session etc
Other
If Other, please specify
What are your specific objectives that you want the speaker to achieve
specific?
What SENSITIVE ISSUES should the Speaker Avoid?
What takes place directly BEFORE The Speakers Slot on the Programme?
What takes place directly AFTER The Speakers Slot on the Programme?
Who are the other Speakers on the Programme?
Which Professional Speakers have you used in the past?
What did you LIKE about their performance?
What did you DISLIKE about their performance?
Please expand a bit on what you would like me to concentrate on based on
your current needs for this audience/ event*
How did you hear about me / Who referred you?
Please select My Brochure  
  My Website  
  Promotional e-Mail Sent by Who?
  An Advert In which Publication?
  A Referral Who?
  An Agent Who?
  Other Details
Preferred method of contact
Please select any number of options Telephone
Fax
e-Mail
Other
If Other, please specify
Submitting this form constitutes an interest for a booking, it does not constitute a confirmed booking.
 
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