Speaker and Expertise Background Form

  
Complete the form below and Click: SUBMIT BACKGROUND INFORMATION button
  Contact Information:
First Name:
 Last Name:
Address:
City/St/Zip:
 / /
Work Phone:
Cell Phone:
Fax:
Website:
Email:
       
  Are you an NSA Member?
  No   Yes, for years
   
  Credentials: (check as many that apply)
  My credentials are based on my business success
  My credentials are based on my research
  My credentials are based on my observations in life
  My credentials are based on my background in training/education
   
  Speaking Emphasis:
  I want to use speaking to support my primary business
  I already use speaking to promote my primary business
      and want to "take it to the next level."
  I want to make speaking my primary business
   
  My Message Focus:
  My message is exclusively personal focused
  My message is primarily personal with some business focused
  My message is primarily business with some personal focused
  My message is exclusively business focused
   
  Newsletter:
  Please add me to the list for Sixty Seconds Speakers' Alert,
      your monthly email newsletter
  Where are you currently in your career? Select one below:
  Paid Professional Speaker Speaking, Paid
Looking at Possibilities of Speaking
   
How many speaking engagements have you had?
 
Paid: Unpaid?
Please list your current fee range:
  Lowest:$ Highest:$
  What is your "umbrella" subject or expertise:
 
  What is your background? What industries have you worked in?
 
  What gives you the right to speak on your subject or expertise (please give three reasons):
Reason #1:
Reason #2:
Reason #3:
  Check the marketing tools you have:
  One-Sheet Speaker's Kit Website
Video Demo Tape Published Book
  List your 3 major needs to develop yourself as
"an expert who speaks professionally":
Need #1:
Need #2:
Need #3: