Position:

Business:

Type of Business:

Email:

Office Phone:

Cell Phone:

Fax:

Website Address:

Topic or Topics you could Speak on,
What would be the benifit to the Attendees of the Clubs?:

Would you be willing to supply us with, your picture and short Bio, your Promo, and an article suitable to be put up on our website?:
Select Yes No

Have you done a formal 30 min. presentation before? If so - Where? Can you create Promotional Materials and provide us with it for the "Networking Table" so that you can be promoted at each Club.

Would you be willing to give the Clubs 10% of any profit
that you make from your appearance at the Clubs?
Select Yes No

Would you be able to speak at all 8 of the Clubs over a year's period?
Select Yes No