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: *

  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: *

Audio/Visual Requirements & 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 one Yes No

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:

Code *