Event Information

Please, copy and paste this form into word, complete the form, and make a copy for your files before e-mailing the form to Margo in an attachment to the e-mail address provided by the agency. The form may expand as you type. Please do not worry about format.

Organization Name: (required)

Meeting Planner/Contact Name: (required)

Your e-mail: (required)

Mailing Address: ___Work Address  __Home Address

Fax:

Telephone: (office)

Telephone: (home)

Telephone: (cell)

Web Site:

Program Information

Date(s) for Margo’s presentation:

Event Type; (mark all that apply)   ___Keynote   ___Breakout Session  ___Workshop ___Lunch & Learn

Please note: If handouts are required they will be e-mailed to you for copying

Event Start Time:                                               Length of Presentation:

Place/Venue:

Place/Venue Phone Number:

Event Room:

Address:

Appropriate Attire for Margo: __Evening __Business __ Casual  __ Business/Casual

Overnight Arrangements

Room Requirements: Non-smoking, hypo-allergenic/fragrance free (if possible). Please make a reservation at a hotel that is convenient to your event and confirm for late arrival.

Lodging will be direct billed to master account: __Yes  __No

Meals will be direct billed to master account: __Yes  __No

Lodging same as presentation location: __Yes  __No    if yes, please skip to Travel Information

Hotel Name:

Hotel Address:

Hotel Phone:

Confirmation Number:

Travel Information:

Margo will make her own travel arrangements and provide you with a copy of her itinerary prior to your event. Travel arrangements will be made only after receiving this completed form.

What airport is closest to the program site?

What other airport (if any) should be considered?

Number of miles from airport to hotel:

Number of miles from hotel to venue:

Ground transportation: Please advise best option:

Room Setup

How will the room be arranged for Margo’s presentation? U-shape if possible for workshops

___Round tables  __Theatre/Classroom __U-shape  __Other, please specify____________________________Tables  __Chairs only

A / V Equipment

Margo requires a projector to which she can hook up her laptop

Microphone: (Please indicate type available)  __Podium __Handheld  __Lapel  __Head set

Very Important – Time Meeting  Room will be empty for set up  _______   __am  __pm (please designate am or pm)

Program title you have selected

___ Help Patients Help You   ___The Missing Piece to Cutting Healthcare Costs  ___ Help Your Clients Help You Help Them   ___Custom Selection from Seminar Topics Please specify topics __________________________________________________________________________

Back Ground Information

What is the purpose of your event?What is the key outcome you would like the attendees to take away from Margo’s presentation?

What is the theme of your event?

How many will be attending the overall event?

How many will be attending Margo’s presentation? Please estimate if you don’t know the exact number.________

Who will be the main attendees? (job titles & responsibilities)

What challenges are your attendees facing?

What are some recent victories?

Who was the previous speaker/entertainer for this group last year?

What was their topic?

Please provide three people I can interview as I make preparation for your event:Name____________________________ Phone Number(s): Office:_________________Cell:__________________ Name____________________________ Phone Number(s): Office:_________________Cell:__________________ Name____________________________ Phone Number(s): Office:_________________Cell:__________________

Agenda:

Once the contract is completed through your bureau, please email a complete agenda of your conference/event to me at the e-mail provided by the agency.When would it be convenient for Margo to talk with you (via phone) about her presentation? Best time to contact you: Date: ____________  Time of Day: ___________

This form was completed by: _________________________Date completed: ______