WELCOA Speaking Inquiry

	Yes, I'm interested in learning more about booking a WELCOA Speaker for my event. Please have a representative contact me at no obligation. (Please fill out the questionnaire below).
Proposed Date of Event:
Proposed Location of Event:
First Name:
Last Name:
Job Title:
Organization:
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State:	Select a state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------------------- Out of US/Canada -------------------------- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon
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Number of Employees:	1-10 11-50 51-500 501-5,000 5,000 +
Any Questions or Comments?
Now please take a moment to tell us about the event you are planning so we may better respond.
Type of Event:
Potential Topic:
Length of Presentation:	Please Select One 60 Minutes 61 - 90 Minutes 91 - 120 Minutes 120+ Minutes
Intent of Presentation: (Please select all that apply)	Inform Persuade Teach Inspire Entertain
Number expected to attend:
Industry of audience: (Please select all that apply)	Manufacturing Corporate Healthcare Academic Small Business Other
Audience's educational backgrounds: (please estimate a percentage each grouping will represent)	% High School or Equivalent % Undergrad % College Degree % Gradutate Degree
Audience's background and knowledge in topic:	Please Select One Basic Intermediate Advanced Expert
Issues and concerns that most affect the audience:	Increasing Productivity Demonstrating Return on Investment Reducing health care costs Transforming Culture Building programs that last Creating a shared vision Other
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