Speakers Academy

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Complete this speakers request form in three simple steps.
Duration:		minutes

	Complete personal information
	Complete specific demands and wishes
	Send / submit

Within 24 hours you will receive a special offer or you will be contacted by one of our account managers.

SPEAKERS REQUEST FORM

* mandatory field

Company Name/Organization*:
Address*:
Postal code*:
City*:
Country:

Contact person*:
Title
Initial(s)*:
Insert*:
Surname*:

Gender*:

malefemale

Telephone number*
Fax:
Mobile/cell phone:
E-mail*:

Add me to your mailinglist

I would like to receive a special offer without obligations based on
the information below::

Date*:
Alternative date:
Where (city/ region)*:

Time(s)*: from until overrun until

Type the name(s) of the speaker(s) of your choice in the box below in case you have not selected a speaker yet (your shopping basket is still empty), or if you want to add one or more speakers to your wish list.

Composition of your audience:

Staff members and co-workers only

Staff members, co-workers and their partners

Business relations

Suppliers

Lower management

Middle management

Higher management

Managing director/board of directors

It concerns:

Lecture

Chairperson for a day

Lecture and chairperson for a day

Performance

Fake speech

Column

Other, specify

Please indicate the expected number of guests:

Kind of event:

For instance:
Congres
Seminar
Symposium
Client Event
Sales meeting
Motivational Event
Business Club event
Introduction new product

Purpose of the event:

Festive event (like jubilee et cetera)
Networking event
Motivational event
Exchange of information
Product launch

Subject/theme:

Budget indication*:

€

750 - 2000

€€

2000 - 3500

€€€

3500 - 5000

€€€€

5000 - 7500

€€€€€

7500 - 12500

€€€€€€

12500 - 50000

€€€€€€€

> 50000

Space for additional information:

Finally!
How did hear about Speakers Academy?

We would like to thank you for filling out this form. Within 24 hours you will receive a special offer or you will be contacted by one of our account managers.

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Questions?

or +31-10-433.33.22

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