Captain Gerald Coffee

MEETING QUESTIONNAIRE

FOR

Organization/Company Name

Date of Meeting 

Time of Meeting  a.m.   p.m.

Thank you for taking time to fill out this questionnaire. In order for Captain Coffee to contribute all he possibly can to the theme and purpose of your meeting, please respond to the following questions. The few minutes required will be more than compensated by the increased effectiveness of his presentation. Your success and the success of your meeting are his highest priority. (Skip any questions that do not apply.)

Address: 

Phone(s): 

Fax: 

Email:    Website: 

Meeting Location (City/State): 

Hotel accommodations: 

Address: 

Phone: 

Fax:

Presentation Location (if other than Hotel): 

Name of this particular group (i.e., Golden Circle, President’s Club, Centurions, etc.)

Commonly used nickname and/or acronym, i.e., Big Blue (IBM), Ma Bell (AT&T):

Commonly used advertising slogan or organization’s motto:

Primary contact person(s) at the meeting site: 

Cell phone/pager: 

 Names of the top senior personnel (& spouse, if in attendance) at meeting

(CEO, Chairman of the Board, President, Vice Presidents, etc.):

Captain Coffee will be introduced by: 

Title: 

Audience size: 

  % Male

  % Female

Age Ranges:

20–30 yrs. %   30-40 yrs. %  

40-50 yrs. %    50 + yrs.   %

Audience Make-up (i.e., top sales executives, managers and spouses, clients, etc.)

U.S. Audience:  % International audience members:  %

Dress code for principles: 

Appropriate speaker attire: 

Theme and purpose of meeting:

What takes place immediately before Captain Coffee’s presentation?

After his presentation?

Current or immediate past successes of organization:

Current or immediate past challenges within your organization/industry, i.e., personnel issues/takeovers/mergers, significant loss of market share, product setbacks, regulation, liability insurance, etc.:

Foreseeable future difficulties or challenges:

What do you hope for Captain Coffee to accomplish with his presentation?

BOOKS and TAPES:

Captain Coffee never mentions products from the speaking platform, but for the same reasons you want to share his message with your attendees, they may want to share it with their families, friends, and associates.

You can make this possible by (please check):

Placing order forms for his book , Beyond Survival , his video and audio cassettes

(1) in each attendee’s registration packet,

(2) on the chairs or tables in the meeting room,

(3) at the registration desk with an announcement of their availability and location,

(4) Other:

Pre-purchasing Beyond Survival for each official attendee or specific key clients or managers, which Captain Coffee would gladly personalize beforehand; It makes a great take home or room gift for incentive meetings.

Do not want to mention, make order forms available, or pre-purchase Captain Coffee’s book, Beyond Survival.

Please print (click here for printable version) and complete this questionnaire and fax it with any related program material no later than 3 weeks prior to the engagement to: (808) 488-0901 or mail to:

Captain Gerald Coffee

PO Box 8

Aiea, HI 96701-0008

If you feel a conference call would be helpful, please arrange it by calling (808) 488-1776.

Thank you!