Road Scholar Speakers Bureau Application

You must make arrangements with the speaker before submitting this application. If you need contact information for the speaker, please contact Celina Chiarello by calling 602-257-0335 X23 or e-mailing cchiarello@azhumanities.org.

Have you confirmed the program date, time and title with
each speaker/presenter?* Yes

Applicant Information

Organization Name:
Are you an eligible applicant? Yes No
Address:
City:
State:	ZIP:
Phone:	Fax:
E-mail:
County:
AZ Legislative District:*	Congressional District:*
To find districts based on address, click here.
Person to contact about this form:
Address:
City:
State:	ZIP:
Phone:	Fax:
E-mail:

Speakers Bureau Program

List the program details here.
Date:	Time:	Speaker/Presenter:	Program:


Is there a fee or meal attached to the presentation(s)? Yes No
Program Location (including street address):
Estimated audience size for each program:
Intended Publicity:

Fee Due to AHC:
No. of Program(s) x $100 =	$
Your Required Contribution: AHC asks that you estimate the value of the resources that you are putting into the project.
Staff and Volunteer Time	$
Services and Materials	$
Other	$
Fee Due to AHC (from above)	$
TOTAL CONTRIBUTION*	$
Payment will be due once your application is processed, and due at the same time as the signed contract.
* Required