Speaking Engagement Interest Form

Name	Title

Organization	Address

Telephone Number	Suite or Apt#

Fax Number	City

Email Address	State/Province

Country	Zip/Postal Code


How did you hear about Jackie?
What kind of speaker are you looking for?

What is the requested date?
Who is the audience?
How many people will attend?
Location of the presentation:
Would you like a press kit & video?	YES NO
Would you like a book signing?	YES NO
When is the best time to call you?