SPEAKER QUESTIONNAIRE

CONTACT INFO: Date:__________________

Speaker Name:_____________________________________________________________

Company Name:_____________________________________________________________

Mailing Address:__________________________________________________________

City/State/Zip (Please use nine digit zip to insure more accurate delivery)

__________________________________________________________________________

E-Mail Address:___________________________________________________________

Shipping Address:_________________________________________________________

City/State/Zip (Please use nine digit zip to insure more accurate delivery)

__________________________________________________________________________

Local Telephone:__________________________________________________________

Toll Free Telephone:______________________________________________________

Fax:______________________________________________________________________

Speaker Home Telephone:___________________________________________________

Web Site:_________________________________________________________________

Bureau Friendly Web Site:_________________________________________________

Scheduling Assistant:_____________________________________________________

Asst. E-Mail Address:_____________________________________________________

Asst. Home Telephone:_____________________________________________________

Asst. Pager:______________________________________________________________

TAX INFO:

Who Is Check Payable To?:_________________________________________________

SSN/Federal ID:___________________________________________________________

Business Structure: (Check One)

Corporation_____Partnership____Individual____

PRICING INFO:

Keynote: $______ How Do You Define Keynote?:

(Check One) Up To 60 min___90 min___ Other___Please Define________________

1/2 Day: $_____ How Do Define Half Day?:

(Check One) Up To 2__3__4__Hours Other___Please Define__________________

Whole Day: $______ How Do You Define Whole Day?:

(Check One) Up To 4__5__6__Hours Other___Please Define__________________

Are Above Prices Commissionable?: (Check One) Yes__________ No__________

Commission Rate______%

Detailed Pricing Info:(East Coast/West Coast,etc.)________________________

Do You Allow Purchaser To Video Tape?: (Check One) Yes________ No_________

If so, How much additional do you charge?_________________________________

TRAVEL INFO:

Hotel Room Specs:

(Check One) Smoking_______ Non-Smoking________

Other:____________________________________________________________________

Air Fare Specs: (Check One) Coach_______ First Class_______

Is First Class Airfare a “Deal Breaker”?:(Check One)Yes________ No________

Which Do You Prefer? (Check One) Airport Pickup________ Rental Car________

GENERAL INFO:

How Long Have You Been A Full Time Speaker?:______________________________

Average Number of Speeches/Year:__________________________________________

Average Fee Per Speech:___________________________________________________

Please List The Names and Contact Information of Three Bureau’s You’ve Worked With In The Last Year:

Please List Professional Awards/Designations and Educational Degrees:

Please List The Qualities Which Make You Unique as a Speaking Professional:

Keywords For Computers To Index You On: (Up to six)

(Such as teamwork, humorist, motivational, sales, technology ,etc)

_____________________________________________________________________

Key Selling Points:

(Such at tv appearances, books authored, major clients, etc)

Industry Specialization:

(financial, healthcare markets, etc)

Topic/Title of Favorite Speech (List Up To Three)

What Percentage of Material Do You Customize?:____________________________

What Percentage of Material Is Original?:_________________________________

PROMOTIONAL MATERIAL TO ENCLOSE CHECKLIST:

B/W Glossy Photo ___ (Lithograph Not Acceptable)

Video Tape ___ (Absolutely, Positively Put Name On Spine

of Video Tape!!!)(Be Sure To Put Date On Spine)

Reference List ___

Reference Letters ___

Newspaper Articles___

Brochure Bio ___ 60-80 Words

General Bio ___

Intro ___

Please Return To:
Barber & Associates

(Mailing Address)                (Shipping Address)
P O Box 11669                    412 Liberty Street
Knoxville TN 37939-1669          Knoxville TN 37919-4520

Telephone: (865) 546-0000
Fax: (865) 673-4680

Please include a completed W-9 with your submission. (Requires Adobe Acrobat Reader to Open the W-9)