Please fill out this form and submit below.
Official Company Name
Division
Where will the event take place?
Address
City, St, Zip
What is Dr. Myers’ role in the program? (Opening or Closing Keynote, Luncheon Speaker, etc.)
Speaker
What did you specifically like/dislike about their performance? Why? Liked: Disliked:
What are your organization’s objectives for Dr. Myers’ presentation?
Audience:
Total number expected
Number of men
Number of women
Are spouses invited?
What do you expect your audience to gain from the presentation?
What three main things should Dr. Myers know about your group? 1) 2) 3)
Who will be the key contact(s) prior and during the event?
Primary Contact
Title
Work Phone
Cell Phone
Secondary Contact
