Bookings

In order for me to effectively manage your request, please complete the following information. Please note that the asterisk (*) indicates a mandatory field. You therefore need to complete these fields in order to submit this form to me.

Your Personal and Contact Information

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Title *

Your First name *

Your Surname *

Your Position in the Business *

Your Telephone number *

Your Fax number

Your Cell number

Email *

Best Time for me to Reach You:

Time Zone (Eg: SA, Europe,or UK)

Your Business / Organisation Information

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Business Name *

Nature of Business / Products etc.

Nature of Business / Products etc

Business Name

Business Physical address *

Physical address line 2

Suburb

City

Postal Code

Business Postal address

Postal address line 2

Suburb

City

Postal Code

Business Email address

Business Web Site address

Business Telephone number *

Business Fax number

Your event

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What is the Occasion *

Please specify event

What is the THEME of the event?

What Events have you had in the past year?

What are the dates for this event?

Speaking Assignment Date and Time Information

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Date *

Time of day *

Duration *

Your Venue Information

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Country *

Region *

City / Town of your Event *

Nearest Airport

Actual Venue of your Event *

Accommodation available?

Yes

Your Audience Information

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Approx. Size of Audience *

Audience mix: % male

Audience mix: % female

Company mix

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% staff

% customers

% open to all

Management / Staff Mix

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% Management

% Staff

% Other

Group Information

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Is this a Specialist Group - If so, please give details

Please list 3 items you believe I should know before addressing this group

What are YOUR goals for this Audience?

Any Other Information that may help me to make this presentation relevant to this audience?

Adult Content – How sensitive is this audience to adult content ?

Your Speaker Requirements & Information

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What would you like Adolph to achieve: (Choose more than one if necessary)

Deliver a Keynote Address

Yes

Deliver a Breakaway or Secondary Address

Yes

Conduct an In-House Training Session

Yes

Deliver a Conference Presentation

Yes

Motivate and Inspire the Audience

Yes

Provide Humour and Entertainment

Yes

MC a Function

Yes

Chair a Conference / Meeting / AGM etc

Yes

Facilitate a Workshop / Brainstorm Session

Yes

Other

Yes

Please specify requirement

What are your specific objectives that you want the speaker to achieve specific ?

What SENSITIVE ISSUES should the Speaker Avoid?

What takes place directly BEFORE The Speakers Slot on the Programme?

What takes place directly AFTER The Speakers Slot on the Programme?

Who are the other Speakers on the Programme?

Which Professional Speakers have you used in the past?

What did you LIKE about their performance?

What did you DISLIKE about their performance?

Please expand a bit on what you would like me to concentrate on based on your current needs for this audience/ event. *

How did you hear about me / Who referred you?

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My Brochure

Yes

My Website

Yes

Promotional e-Mail

Yes

Sent by Who?

An Advert

Yes

In which Publication?

A Referral

Yes

Who?

An Agent

Yes

Who?

Other source

Yes

Please specify source

Preferred method of contact

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Please select any number of options

Phone

Yes

Fax

Yes

Other method

Yes

Please specify method

Adolph Kaestner

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Your Personal and Contact Information

Your Business / Organisation Information

Your event

Speaking Assignment Date and Time Information

Your Venue Information

Your Audience Information

Company mix

Management / Staff Mix

Group Information

Your Speaker Requirements & Information

How did you hear about me / Who referred you?

Preferred method of contact

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