Wufoo

Name of Your Contact Person * First Last
Your Group or Organization *
Maximum Allowed: 100 characters. Currently Used: 0 characters.
Address of the Contact Person *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number * ### - ### - ####
Email
Website
What is the date or possible dates of your event? *
Maximum Allowed: 50 characters. Currently Used: 0 characters.

If you have a few different dates in mind, please indicate this. And your preference. If a single date, then just enter that date.
How many people do you expect at the event? *
Maximum Allowed: 10 characters. Currently Used: 0 characters.
Where will this event be held? *
Maximum Allowed: 150 characters. Currently Used: 0 characters.

If you have not booked the exact location yet, just indicate the place you expect it to be held.
Which one of these best describes your group? *
Professional - Medical/Hospital Professional - Insurance/Finance EmployerAssociation/Employer Service Association Association - Medical/Hospital Association - Insurnace/Finance Association of Businesses, i.e. Chamber of Commerce Manufacturing - Medical Device/Pharma/Medical products Academic Political Group Church or Faith Institution Other

Dave speaks at a variety of groups, adapting his talk to specific needs. Please choose the category in the drop down list that comes closest to your group. You may be involved with more than one of these in your local community, and might wish to invite Dave to speak at more than one event while he is in your town.
What is your budget for a speaker? *
Maximum Allowed: 100 characters. Currently Used: 0 characters.

Host groups are responsible for Dave's travel expense. Dave is committed to keeping your expenses low, and plenty happy with coach travel, and "Holiday Inn Express" lodging. We also need to know how much you have budgeted for an honorarium. Please let us know your terms.
Date you will decide whether to book Dave

We will respond to your request within 48 hours. Once we do, when will your group or you be able to decide whether Dave will be speaking at your event?
Please add any information you feel is relevant.
Maximum Allowed: 500 characters. Currently Used: 0 characters.
Do Not Fill This Out