Steve Philbrick’s
Pre Program Questionnaire
This questionnaire is
designed to help Steve prepare the best possible customized presentation.
Please print and return to
us no later than 10 days before meeting. Thank you!
Name of Group:
_______________________________
Date of Presentation:
___________
Person completing this
form:_____________________ Phone:
( ) ___________
Fax #: (_____)
_________________________
Email address:
______________________
WWW address: ______________________________________
Meeting time: Begin
____________ End ___________________
My Program: Begin
____________ End ___________________
2nd program:
Begin _____________End ___________________
Meeting Location:
_____________________________________
Address:
____________________________________________
City:
_____________________________________________
Hotel Address:
________________ Phone #:______________ Fax#:_________________
Closest
Airport:______________________ # miles from site:________________________
How would you prefer that
I dress: In a suit & tie? ______
Business casual_______
Casual? _______
Approximate # attending
meeting: _______ f_____ (%) m_____(%)
Age range__________
General Job
responsibilities of attendees: _______________________________________
If this presentation is
part of a conference, what is the theme, if any?
What are some problems /
breakthroughs / challenges currently experienced by your company or industry?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Overall objectives of meeting
or conference:
Top People to recognize in
the audience or people to poke “fun” at:
Name:
___________________________ Title: _____________
Reason: ______________
Name:
___________________________ Title _____________ Reason:______________
Specific objectives for
Steve’s presentation:
Any seeds you would like
Steve to plant:
Any special recognition
you’d like Steve to give to members of you organization?
Name:
_________________________ accomplishment _____________________
Name: _________________________
accomplishment _____________________
Schedule: What will be
happening before and after presentation?
Introducer or master of
ceremonies?
Name: ____________________________ Title: ____________________________
Thank you very much for helping Steve to customize his presentation
for your group!
This form can either be
faxed or mailed. Please return at least 10
days prior to scheduled meeting. P. O. Box 5494 Suffolk,
VA 23435 757-484-8512 · fax ·
757-488-0915 Steve@StevePhilbrick.com