Jairek Robbins Speaking Request

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* 1. Contact information:

Name: *

Company: *

Name of the Event: *

Address :

City/Town: *

State/Province:

Country:

Email Address: *

Phone Number: *

Skype User Name: *

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* 2. What is the location of the event?

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* 3. Date and Time of event?

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* 4. Planned # of attendees:

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* 5. Who else will be speaking:

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* 6. Price to attend this event (If there are packages available... What are the package prices?):

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* 7. Will anything be sold at this event? (If Yes, What will be sold? Price point?)

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* 8. Speaker Budget:

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* 9. What is your attendees primary focus in life?

Business/Entrepreneurship

Love/Relationships

Health/Fitness

Freedom/Fulfillment

Finances

Spirituality

Time Management

Other (please specify)

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* 10. Is there a specific profession that most of your attendees would be grouped under?

Entrepreneur

Manager

C-Level (CEO/CFO/COO)

Employee

Internet Marketer

Coach/Speaker

Student

Author

Service-provider

Other (please specify)

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* 11. What is the biggest PROBLEM your attendees faces?

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* 12. What do your attendees want MOST in life?

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* 13. What do you feel is keeping them from achieving what they want most?

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* 14. What topic(s) would you like Jairek to focus on during the Speech/workshop?

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* 15. How did you become aware of Jairek Robbins?

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* 16. Please list 3 references and their contact (e-mail/Phone)

Reference #1

Reference #2

Reference #3