Program Request Form

To help us, help you, please answer the "Success Sixteen." Thank you!

Fields marked with an asterisk * are required.

*Name
*Title
*Company
*Address
*City
*State
*Zip Code
*Country
*Phone
*Fax
*E-mail
Web Site

1. What is the date of your meeting?
   

2. Which topic(s) are of greatest value to you?

   please check the appropriate box(es):

   Opportunity $ellingŪ/Your Path to ProfitŪ
   The Customer Commitment
   Negotiating Know How - The Power of "Yes"
   Referrals: Your Road to Results
   Change: Capsize or Capitalize
   Marketing Magic
   Manage, Move & Motivate
   Creating your own "TV" Telecast
   Personal Success Coaching

3. In what city/site is your meeting?
   

4. What's the purpose of your meeting?
   

5. What is your theme?
   

6. What is the size of your audience?
   

7. Who is in the audience? (i.e., CEOs, Presidents, sales and marketing professionals, managers and supervisors, executive leadership team, front-line employees, spouses, etc.)
   

8. What are your goals for this meeting?
   

9. What might be the length of Jeff's presentation(s)?
   keynote: 45 to 60 minutes
   seminar/workshop: two to four hours
   seminar/workshop: 5 to 7 hours
   other: (multi-day, etc.)

10. Following Jeff's presentation, what outcomes or results do you want to achieve?
    

11. What's your budget range, (excluding expenses)?
    

12. Aside from you, who else might be involved in making this decision?
    

13. When do you want to decide by?
    

14. What type of information would help your decision?
    Jeff's brochure and promotional materials
    Jeff's video-preview tape
    client references
    chatting with Jeff, to discuss your specific goals and objectives
      

15. How soon do you need this information?
    

    Or, when would you like to visit with Jeff?
    

16. When is the best time to contact you?
    

            

    Blackman & Associates, Inc.
    Creating Profits Through People^®
    2130 Warwick Lane
    Glenview, IL 60026
    847.998.0688
    Fax: 847.998.0675

    jeff@jeffblackman.com
    sheryl@jeffblackman.com

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