Event/Retreat Speaking- Agent/Broker Questionnaire ™ “Coach Super Mike” is looking forward to attending your event. Kindly provide answers to the questions below. Upon completion of the form below, “Coach Super Mike” will follow up with you to set up scheduling. 1. Company/organization name: * 2. Company/organization address: 3. Company/organization office phone number: 4. Contact name: * 5. Contact Cellular Phone Number: 6. Contact email address: * 7. How many agents do you anticipate attending your event? 8. What is the name of your event? 9. What is the date of your event? 10. What is the start time and end time for your event? to 11. What day/time do you need “Coach Super Mike” to arrive by? 12. What is the address and the name of venue for your event? 13. Please select which format closely matches your event Class or session that is led only by “Coach Super Mike”Class or session that is led by “Coach Super Mike” and another presenter. If so, what is the focus/topic that they will be addressing?Panel- If so, how many panelist will there be, what are their names and what topics will they cover or address?Question and Answer SessionOther- Please describe 14. What are the format details for your event and kindly include any agenda? 15. Regarding technical details, please confirm that your company/organization will have the following items prepared and ready for the start of the event by indicating YES or NO and provide any notes: a. A tested sound system with microphone. b. Do you know if the microphone is wired, wireless, lapel or a combination of all? c. Laptop with PowerPoint AND internet access. Please note that “Coach Super Mike” will bring his own PowerPoint presentation on a memory stick. d. Projector/screen for the PowerPoint presentation e. Ability to play music f. A point person on your team who will handle technical issues 16. Please provide a name and contact information for the person from your company/organization will be coordinating payment and travel accommodations for “Coach Super Mike”? 17. What topic(s) would you like Coach Super Mike to address during the event? a. b. c. d. e. 18. Did you survey your organization for the event topic(s) or did you select them? 19. Is there any specific content that you’d like “Coach Super Mike” to include in his presentation? 20. As team leader/broker/leader of your organization, what goal would you like to accomplish over the next 30 days? 21. As team leader/broker/leader of your organization, what goal would you like to accomplish over the next year? 22. Tell “Coach Super Mike” about any items of importance that he should be aware of? a. b. c. d. e.