Contact Information form

If you are interested in having Joseph Daniels perform at one of your events, please take a moment to fill out the customer information form below. Please include as much information as possible. If you are simply trying to reach Joseph, you may also use the contact information found at the bottom of the site.

NAME:

CONTACT NUMBERS:
Home :    Work :    Cell/Other :

EVENT:
Type: If Other, please explain :
Title (if applicable) :

COMPANY NAME (IF APPLICABLE):

CONNECTION TO THIS EVENT:

DATE/TIME:
Month :      Date :      Year :

Location/Physical Address of Event:
Address :
Suite :
State:      Zip :

Mailing Address:     Same as above:
Address :
Suite :
State:      Zip :

How did you find us?:
Previous Meeting
Referral      Who? :
Business Card
Another Company's Website
      Site :
Search Engine      Which One? :

Approximate Event Attendance:

Approximate Event Budget:

Description of Event:

SERVICES YOU'RE INTERESTED IN:

Illusions (Stage Magic)
Strolling (Close-up interactive)
Party
Soiree

Cocktail Hour or Private Function
Motivational
Master of Ceremonies
Specialty Show

Special Requests/Requirements:

I would like to join the Joseph Daniels Mailing list so I can find out about upcoming events, updates to the site, and other exciting news!

Thank you for your time