Contact Information

Please assist me and my staff in customizing a program that is specifically suited to the needs of your group. The answers to this questionnaire will help me tailor my presentation appropriately. Please skip any questions that are not relevant to your group. In addition to this questionnaire, please provide me with any written, printed or web-based materials that will help me familiarize myself with the upcoming event.

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. At what email address would you like to be contacted?

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* 4. Phone Number:

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* 5. Cell Phone:

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* 6. Organization Name:

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* 7. Name and cell phone number of person to contact at event (if different from above, important while traveling):

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* 8. Name and email of person who will be reading Brian’s introduction (please make sure you receive our Google Doc with multiple bio options and get it to them):

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