Organization requesting talk:
Contact Person:
Address:
Phone:
Email:
Event Date[s]:
Event time:
Location: (City)
(State)
Maximum length of presentation:
Anticipated number of attendees:
Is your organization:
for-profit
non-profit
The following will be paid by the host organazation:
Travel
Mileage ($.51/mile)
Air fare
Shuttle
Accommodations
Hotel/Motel (No private home accommodations, please)
Meals
Honorarium Amount:
(Payable to IHSF)
Will the above be direct payments or reimbursements?
To whom should receipts for reimbursements be sent?
Topic of Speech:
Please print this form and mail to the address below:
P.O. Box 36 Mesilla Park, New Mexico 88047 U.S.A.
Telephone: 575.525.3035 Fax: 575.525.0106 info@ihsf.org