Speakers Bureau Request

Organization Address *

County *
Program Coordinator Name *

First Name Last Name
Program Coordinator Email *
Phone Number *

- Area Code Phone Number
Fax Number

- Area Code Phone Number
Organization Category *

Non-profit, annual budget less than $50,000 Non-profit, annual budget greater than $50,000 For-profit
Have you partnered with MHC or had an MHC grant in the last five years? *

No Yes
Program Details
Speaker and Program *
Program Date and Time *

/ Month / Day Year
Date
at
: Hour Minutes
Alternative Date and Time *

/ Month / Day Year
Date
at
: Hour Minutes

Program Location *

Estimated Size of Audience *
Minimum of 15 for small organizations and 25 for large
What is the intended audience for this program?
Who are your co-sponsoring organizations (if any)?
Please tell us how you plan to publicize the program and how you will invite participants to attend.
Please be advised that attendees will be required to complete a brief evaluation form following your program.
Should be Empty:

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