Pre-Program Questionnaire

Please fill out the form below, or download the PDF and fax or mail it to:

Rick Segel & Associates
268 Hamrick Drive
Kissimmee, FL 34759

Fax: 800-847-9411

Contact Name *

Name of organization *

Email (we will keep your email completely private) *

Composition of audience

Number expected to attend?

Length of presentation?

What is the theme of the meeting?

What are the specific objectives/results desired from our program?

What is the mission/philosophy statement of your organization?

What are some of the current problems/challenges/breakthroughs expierenced by your industry?

Are there any sensitive issues or terms to avoid?

What time does the meeting start?

What time does the meeting end?

Meeting site

Address

City

State

Zip

Distance from airport to hotel

Distance from hotel to site

Recommended mode of transportation from airport to hotel?

Recommended mode of transportation from hotel to meeting site?

What takes place directly before our program? (Meal, break, etc., if another speaker please indicate the topic)?

What takes place directly after our program? (Meal, break, etc., if another speaker please indicate the topic)?

If problems/emergencies arise on the way to the program, whom should we contact?

Business telephone number

Mobile telephone number

Names and telephone numbers of general managers, employees, and/or addociates we can contact to get additional information?

Previous consultants and/or programs used

Name and telephone number of people you would like to refer to Rick Segel & Associates

Proactive business: