BEG Centennial Distinguished Lectures Request Form

Bureau of Economic Geology Centennial Distinguished Lectures Request Form

Please provide the requested information and submit this form to request a Distinguished Lecture.

Name of organization:

Contact Person:

Address: City: State: Zip code:

Phone (incl. area code):

Fax (incl. area code):

Email address of contact person:

How your organization can provide assistance to our distinguished lecturer:

Transportation to and from airport? yes no

Transportation to hotel? yes no

Transportation to venue? yes no

Will organization work with local affiliated groups to promote event? yes no

What other affiliated groups will organization work with? (please specify)

Preferred Lecturers:

Lecture title first choice

Lecture title second choice

Venue where lecture will be held

Event date: (mm/dd/yy)

Event time:

Venue maximum seating capacity:

If venue contact person is other than indicated above, please specify alternate contact information here:

Contact Person:

Address: City: State: Zip code:

Phone (incl. area code):

Fax (incl. area code):

Email address of contact person:

Human Verification
This human verification mechanism is used to make sure automated means are not used to fill out and submit this form. Type the two words shown into the text box.

Distinguished lecture Series

Distinguished Lecturers: