Name:*

Email:*

Telephone Number:*



Additional Information:

Company Name:

Street Address:

City/State:

Zip Code:

Fax Number:

Web Address:




Please tell us a little more about your requirements:

What is your specific purpose in hiring a professional coach/trainer? Please describe the situation, intentions, and specific desired results:



How many people do you require training for?

Have you or your company hired a professional coach/trainer before? If so, for what purpose?



Who are the people in your company that are needing training?
CEO       Senior Executive       Staff       Marketing Team
Other (please explain):


If you are contacting us regarding speeches or presentation skills, how many speeches or
presentations do you give?

Per month:  


Per year:



What is the nature of your presentation or communication?
Motivational     Interview Skills     TV and Radio Appearance    
Large Audience Presentation    Specialty and Social Event Speeches
Team Building and Empowerment     Speech Writing and Conference Design  
Other   Please Describe:


To whom do you deliver presentations, conferences, communication, etc?



How did you hear about us? Please be as specific as possible:



What is the best time to reach you?



What additional information do you need? Or questions that you have:

If you have an audio or video presentation that you would like Eric to critique, please click here.