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Contact Information
Church, Organization or Business Name*
Primary Contact Name*
First Last
Title
Phone*
Email*
Your role in organization*
- Pastor
- Staff
- Elder/lay leadership
- Community leader
- Non-profit director
- Business leader
- Board member
- Shareholder
- Other
Type of Presentation
Service Requested*
- Speaking engagement
- Workshop facilitation
- Consulting service
- Demographic Tour
- Other
Date
MM slash DD slash YYYY
Time

: Hours

Minutes

AM/PM
Location
Street Address Address Line 2 City State ZIP Code
Please let me know...
How did you hear about Susan Nichols & Community Connections Consulting?
What would you say is your biggest need in your organization?

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Fees are based on the specific service request and will be discussed in the initial consultation after the Service Request Form is received.

Contact Me

susan.nichols@yahoo.com
281-782-5818

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