Speakers Bureau Application

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

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

Applicant Information

Organization Name:
Is this a Speakers in the Schools Program? (if yes, you may skip the Publicity and Fees Due sections of this application) Yes No
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:

Program Information

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:

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*	$

Intended Publicity:

Fee Due to AHC:
No. of Program(s) x $100 =	$
Payment will be due once your application is processed, and due at the same time as the signed contract.
* Required