Event Questionnaire Step 1 of 3 33% When completing the Personal Appearance Questionnaire, please include as much information as possible. It is especially helpful to have the “other possible dates” line completed. We are currently scheduling appearances for weekdays and evenings and Saturday mornings. Due to Jeff’s fulltime position as Lead Pastor, Sunday appearances are no longer being accepted. Once completed, the information will be reviewed by Jeff Struecker, LLC and then you will be contacted. Thank you for taking the time to complete the questionnaire. We look forward to the possibility of working with you The following is a request for Jeff Struecker to appear at an event.Requested Date of Event MM slash DD slash YYYY Alternate Date of Event MM slash DD slash YYYY Client/Pre-Event Contact InformationOrganization Contact Name First Last Position with Organization Office PhoneOffice FaxMobile PhoneHome PhoneEmail Onsite Contact InformationIs the onsite contact person different than the person above? Yes No Contact Name First Last Position with Organization Office PhoneMobile PhoneHome PhoneEmail Venue InformationVenue Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Main PhoneVenue FaxNearest Major Airport(s) Venue Distance from Airport Event ScheduleTimezone of Venue Eastern Central Mountain Pacific Other Local Time Zone of Venue Setup/Sound Check Time : Hours Minutes AM PM AM/PM Time Doors Open : Hours Minutes AM PM AM/PM Time Event Begins : Hours Minutes AM PM AM/PM Time Jeff Presents : Hours Minutes AM PM AM/PM Time Event concludes : Hours Minutes AM PM AM/PM Time Jeff may depart : Hours Minutes AM PM AM/PM Length of Jeff Presentation Additional Presentation DetailsEvent Details OverviewEvent Name Event PurposeDescriptionMain ObjectiveTheme/Topic Preferred speaker attire Casual Suit Other Other attire? Person Introducing Speaker Audience DemographicAudience DescriptionExpected Attendance Age Range Percent Audience Male Percent Audience Female Percentage audience familiar with speaker Percentage audience who are military Miscellaneous DetailsOther speakers or entertainers at eventDescription of host organizationOrganization Website Proposed Honorarium Additional helpful information The above information and proposal will be reviewed by Jeff Struecker, LLC. If this appearance proposal is agreed upon by both parties, Client consents to reimburse Jeff Struecker, LLC for all travel expenses including but not limited to mileage or flight expenses (with option for companion fare), rental car and lodging in accordance with the Personal Appearance Contract to be signed by both parties. Neither video nor audio recording allowed at event without prior express permission given solely by Jeff Struecker. If express permission is granted by Jeff Struecker, Client agrees to never release said recordings for profit. All information given on Personal Appearance Questionnaire is privileged and confidential. An Appearance Contract must be signed and deposit received by Jeff Struecker, LLC for a scheduled appearance to be confirmed. Please see Appearance Contract for other Terms and Conditions.PhoneThis field is for validation purposes and should be left unchanged. Δ
