Request Personal Appearance 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 Date Format: MM slash DD slash YYYY Alternate Date of Event Date Format: MM slash DD slash YYYY Client/Pre-Event Contact InformationOrganizationContact Name First Last Position with OrganizationOffice PhoneOffice FaxMobile PhoneHome PhoneEmail Onsite Contact InformationIs the onsite contact person different than the person above? Yes No Contact Name First Last Position with OrganizationOffice PhoneMobile PhoneHome PhoneEmail Venue InformationVenue NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Main PhoneVenue FaxNearest Major Airport(s)Venue Distance from AirportEvent ScheduleTimezone of Venue Eastern Central Mountain Pacific Other Local Time Zone of VenueSetup/Sound Check Time : HH MM AM PM Time Doors Open : HH MM AM PM Time Event Begins : HH MM AM PM Time Jeff Presents : HH MM AM PM Time Event concludes : HH MM AM PM Time Jeff may depart : HH MM AM PM Length of Jeff PresentationAdditional Presentation DetailsEvent Details OverviewEvent NameEvent PurposeDescriptionMain ObjectiveTheme/TopicPreferred speaker attire Casual Suit Other Other attire?Person Introducing SpeakerAudience DemographicAudience DescriptionExpected AttendanceAge RangePercent Audience MalePercent Audience FemalePercentage audience familiar with speakerPercentage audience who are militaryMiscellaneous DetailsOther speakers or entertainers at eventDescription of host organizationOrganization Website Proposed HonorariumAdditional 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.NameThis field is for validation purposes and should be left unchanged.
