Sponsoring Organization
Contact Name
Contact Position
Contact Phone/Fax #
Contact Email
Contact Address
Organization's Mission
Is organization a 501 (c)(3)
YesNo
Relationship with Dept of VA
Website URL
Audience Expected
Is this program solely for Veterans?
What type of Veteran program
What level of life experiences?
Will this event be videotaped?
Due Date for Materials/Biography
Contact info to send material
Date of Program
Time of Program
Location of Program
Name of Program
What is the Theme/Purpose
Requested Speaker (if you are interested in a particular speaker)
Proposed Topic(s)
Time of Speaker's Presentation
Length of Presentation
Presentation Format