2021 SAI Provider Information Form

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2021 SAI Provider Information Form

Please contact Kevin Daugherty(or Carol until 11/25) to schedule an AITC presentation or add to form below if you already have a time determined
kdaugherty@ilfb.org
charms-garman@ilfb.org

Please complete by January 11, 2021

Note: AITC presentation blackout dates 6/28/21-7/2/21

SAI Event Name *

Name can be updated/changed at a later date. Name is listed in online brochure

SAI Contact Name *

First Name Last Name

SAI Entity Name *

Will be used in online brochure

Entity Address *

Street Address

Street Address Line 2

City State

Zip Code

Contact Phone *

Area Code Phone Number

Contact Email Address *

SAI Date Range or Individual SAI Dates *

Example: 6/1/19 - 6/5/19 or 6/1, 6/3, 6/5

SAI Location *

Can be edited or added at later date

SAI Grant Reimbursement Level - Please choose one *

$1,500 (45 hours over 6 day minimum) $1,000 (30 hours over 4 days minimum) $750 (22.5 hours over 3 days minimum) $500 (15.5 hours over 2 days minimum) $250 (7.5 hours over 1 day minimum)

AITC Presentation? Choose one *

3 hour AITC presentation 2 hour presentation No AITC presentation

IAITC Presentation Date - if date is already taken, Carol will contact you to reschedule

Date

IAITC Presentation - Start Time Requested

: Hour Minutes AM/PM Option

IAITC Presentation - End Time Requested

: Hour Minutes AM/PM Option

Comments/Questions