Jim Richardson's
Program Request Form:

Jim can customize his talks to meet your needs. So, please describe your group and the theme of your event:

Please enter:

Your name:
Your title:
Company or group:
Postal Code:

Work phone number:
Work FAX number:

Home phone number:
Home FAX number:

Voice Mail:

Cellular phone number:


Email address:

Please enter your type of group:
Government Agency
Health Institution
Educational Institution
Service Club
Other (please specify in blank below)

If you wish Jim to give his keynote speech, please check the length:
15-20 minutes
20-30 minutes
30-45 minutes
45-60 minutes
One hour
1 1/2 hours
Other (please specify in blank below)

If you wish Jim to lead his seminar(s), please check the length:
20-30 minutes
30-60 minutes
1 1/2 hours
2 hours
3 hours
4 hours
5 hours
Other (please specify in blank below)

TOTAL length of time you will have Jim speak at your engagement:

Please indicate the fee you are offering Jim to speak . . .
Date of engagement:
Day of the week:
Other (please specify in blank below) Tentative start time for Jim's first presentation: A.M. or P.M.
Tentative ending time:

Location of event:

Name of venue:
Street Address:
Nearest cross street:
Venue contact person's name:
Their title:
Venue contact's phone number:

Will you be introducing me?
If the answer to the above question is a negative, please email Jim those details ASAP.

Please take one last look at this Program Request Form
to make sure that you have given Jim all the information Jim needs to contact you,
then check here to confirm your request: correct

Thank you for the opportunity to soon be discussing your program.

Now, to submit your order, first make sure you have entered your e-mail address in the above text box.

To submit this form please:

This program is supported by most major browsers. But, if you haven't received a confirmation email back from Jim within two days, then please bug Jim by e-mail at: jim@jimrichardson.com or phone Jim at: 415-877-4424.

You can also print this form, check to make sure that all blanks printed out,
and then mail it to Jim at:

Jim Richardson
PO Box 992
Mill Valley, CA 94942

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