If you are interested in hosting or sponsoring Marriage Motivational Series
or having Dr. Samms speak at one event, please complete and submit the following
request form to: Fax - (904) 765-2000 (Please call us at 904-765-2000 before you fax)

CONTACT INFORMATION                     send to printer

NAME:___________________________________________________________________________________

ORGANIZATION OR CHURCH:______________________________________________________________

CONTACT PERSON:________________________________________________________________________

PRIMARY PHONE: ( ) ________-___________ ALTERNATE PHONE: ( ) _______-_____________

E-MAIL: __________________________________________________________________________________

STREET: __________________________________________________________________________________

CITY: _______________________ STATE/PROVIDENCE_____________________ ZIP:_______________

EVENT INFORMATION - Please choose the package you prefer:

( ) Full Presentation Series ( Lunch will be provided )

( ) One-Time Speaking Engagement - Please call for available dates

( ) Short Presentation Series

DATE OF EVENT

1 ST CHOICE: ____________________________ 2 ND CHOICE: ____________________________________

LOCATION OF EVENT: ____________________________________________________________________

ADDRESS OF EVENT: _____________________________________________________________________

ESTIMATED ATTENDANCE: ______________ NEAREST AIRPORT: _____________________________

Although all of Dr. Samms' presentations will include most of the topics included in his books, Making
Marriage Meaningful and Paradigms of Marriage, please choose 4 of the 10 topics listed in order for us to get a better insight of what interest you most.