Einstein Alive, Motivational Speaker, Business Innovation, Arden Bercovitz, Ph.D., CSP, "The Einstein Guy"
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PreProgram Questionnaire
Part 1

Privacy Guarantee: We will not sell, rent, or give away your e-mail address or other personal information without your consent. All information provided in our Pre-Program Questionnaire is kept in strict confidentiality.

1) Contact person at the event?
Phone: (W) (H)

2) If there is an emergency during travelling, who should be contacted
(Please include an "after-hours" contact)?
Emergency Back-up:

3) Event location:
Phone: Fax:
Event Room:
Distance from hotel: Distance from airport:

4) Audio/visual requirements confirmed:
Arden requests a cordless lavaliere microphone, the largest screen possible, placed as high as possible, off to the side, and good lighting that doesn't wash out the screen. Additionally, (preferred), a projector system, ready for Arden's laptop computer input, using Power Point presentation software, on a table that also holds props, preferably with a remote. Have arrangements been made?
(Please also provide water--no ice)

5) "Picture This!" Photo Opportunity--If you would like your guests to have their photo taken with Einstein (you can even put your logo in the background), please indicate so here . There is no additional charge when adjacent to Einstein's presentation. Custom photo covers are available for a nominal charge. You will need to provide a photographer, film and development.

6) The hotel where Arden will be staying (if different from above). Please put both hotel and fax on master account. Meals and tips will come from per diem.
Phone: Fax:
Mileage and travel time from airport:
Confirmation Number:

7) Person picking up and returning Arden to airport:
Phone: Cell/Pager:
Will driver be at gate? Baggage Claim? Curbside? (Driver should have a sign that says "Bercovitz.")

Would you prefer Arden rent a car and submit expenses?
(Also please provide directions from car rental to hotel where appropriate)


Arden would like to have his product available for your audience after he speaks. Will he be permitted to sell his products following his presentation? (Product consists of Einstein Tapes, T-shirts, Mental Minders, Schlimmbe™ buttons, etc.). If yes, we can arrange this in two ways.

A. Group purchase in advance for each attendee.
B. Materials made available outside meeting room after presentation.

If you choose A, a separate invoice will be sent for product and shipping. If you decide B, please make sure that nothing will be happening after Arden's presentation for at least 15 minutes, a table and chairs will be made available outside the meeting room, someone from your group will be available to assist Arden.

Please indicate the one that is most appropriate for your group.

Your name:
Mailing address:
City: State: Zip:
Phones (direct): (home):
Email address:

A copy of this finished form will be e-mailed to you.


Please verify your email address, this is extremely important.
If you have questions, please email or call

Thank you for your insights, time, and assistance.

Albert Einstein Diversity and Communication quotes
"Problems cannot be solved at the same level of consciousness that created them."
Read Diversity and Communication Quotes by Einstein...
Anne Tiernan, Exec. Dir., Seattle Federal Executive Board

What a charge Dr. Einstein turned out to be! The audience was expecting some industry corporate guy; imagine their surprise, and delight, when Albert Einstein, in his gray flannel vest, sauntered to the microphone. It was rich! He was a high-water mark for our event.
- Rick Altman, Meeting Planner, CORELWORLD User Conference

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