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Pre-Program Questionnaire

To help Dr. Dilip Abayasekara customize his presentation for your group, 
please fill out as much of this Pre-Program Questionnaire as possible.

Once this form has been completed, 
print the form and
fax to: 717-728-2296
or mail to: P.O. Box 405, Enola, PA 17025

Contact Info

Full Name
Title
Company/Organization
Phone
Email Address
Fax
Website URL

Best time for Dr. Abayasekara to reach you (Mon - Fri)

  From  

To  


(In 90 words or less)
Specific purpose of this meeting (award banquet, anniversary, celebration, annual conference, etc.)

(In 90 words or less)
What is the program theme?

(In 90 words or less)
Specific objectives you desire from Dr. Abayasekara's presentation?

Who is responsible for calling the meeting?

Name
Title

What is the name and title of Dr. Abayasekara's introducer?

Name
Title

Time frames for Dr Abayasekara's presentation?

Start
End

(In 90 words or less)
What is on the program just before Dr. Abayasekara speaks?

(In 90 words or less)
What is on the program just after Dr. Abayasekara speaks?

Appropriate Dress Code for the meeting?

Tuxedo
Suit & Tie
Slacks & sport shirt 
Client provided "Theme shirt"

Who are the other speakers on the program?

Name
Topic
Name
Topic
Name
Topic

(In 90 words or less)
What did you like and/or dislike about previous 
presentations given at meetings such as this for your group?

Liked
Disliked

(In 90 words or less)
What would make Dr. Abayasekara's presentation really special for your group?

Will Dr. Abayasekara's presentation be taped?

Yes     No

If so, name the recording company, and provide their contact information.

Company
Phone
Contact Person

To reinforce the impact of Dr. Dilip Abayasekara's ideas after his presentation, 
would you like information about how he can make his learning materials available?

Yes      No

The Audience

Number Expected?
Male/Female Ratio?
Age Range?

Will Spouses be Attending?       Yes      No

Educational Background
Income Range
 


Major job responsibilities of the audience

(In 90 words or less)
Problems/challenges?

(In 90 words or less)
Breakthroughs/milestones?

(In 90 words or less)
What separates your high performance people from others?

(In 90 words or less)
Mission of your organization

(In 90 words or less)
Vision of your organization

Travel Information - Venue

Name of Hotel/Conference Site
Street Address

City  
         

State

Country
Nearest Airport


How will Dr. Abayasekara be transported from the airport to the meeting site?

 

Will be picked up by...

Phone number of person above


Taxi Cab:  approx. fair



In Case Of Emergency

Whom should Dr. Abayasekara contact in case of emergency?

Name 
Phone (Day)
Phone (Evening)



Referral Source

How you found Dr. Dilip Abayasekara

Heard Dr. Dilip speak
Read an article by or about Dr. Dilip
Personal contact with Dr. Dilip
Referral
National Speakers Association
Liberty Bell Speakers Association
International Speakers Network
Toastmasters International
Web Surfing
Other

Describe (In 90 words or less)

Once this form has been completed, 
print the form and
fax to: 717-728-2296
or mail to: P.O. Box 405, Enola, PA 17025

 

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Dilip Abayasekara, Ph.D., A.S.  |  Mailing Address: Dr Dilip, PO Box 405, Enola, PA 17025
Phone: 717.728.2203    |    Cell: 717.648.1080    |    Fax:  717.728.2296

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