Requesting Host
Name of Organization
*
Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Coordinator/ Point of Contact
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Presentation/Speech Details
Date
*
-
Month
-
Day
Year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Audience
*
Expected size and demographics of audience
Back
Next
Logistical Information
Please be aware that the publicity of the seminar is the responsibility of the community, i.e. passing out flyers and registration.
Please select the payment option that best suits your community:
*
Please Select
Attendees with pay $10.00
Community Center will cover the cost of the circle ($2,000 - $2,500)
Cannot afford payment
Additional Information
Information needed from Miftaah Institute (please check all that apply)
Speaker Bio
Photo of Speaker
Flight Itinerary
Other
Additional Information and/or Requests
Submit
Should be Empty: