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Name(s):
Sponsoring Organization:
Phone:
Fax:
Email:
Mailing Address:
City:
State:
Zip:
Honorarium Rate Quoted: $
Date:
College/University
Other (check one)
Requested date(s) for proposed booking: (List two)
1)
2)
The seating capacity for this lecture/screening is:
Will general admission be charged:
Yes
No
Proposed admission price:
List sponsors of the events:
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