 Federation of Alliances Françaises, U.S.A., Inc. A 501(c)3 not-for-profit organization founded in 1902 National Office: 1800 East Capitol Drive, Milwaukee, WI 53211 USA TEL: 800.6.FRANCE FAX: 800.491.6980 www.afusa.org NATIONAL SPEAKERS’ BUREAU NOMINATION FORM N.B. If a member Alliance is submitting this form, please contact the speaker/artist directly to obtain his/her written approval for the nomination. A speaker or artist may send a self nomination | ||
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Name of Speaker or Artist: Mailing Address: _____________________________ Phone: _______________________ E-mail: __________________ Fax:___________________ Type of Program Proposed (circle one) Lecture Music Dance Theater Other: _________________ Brief Background of Speaker or Artist (use separate sheet) Title and Description of Lecture(s) or Program(s) (use separate sheet) Fee or Honorarium (per performance): Technical requirements (if any): ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Nominated by: __________________________ Mailing Address: ________________________ Phone: _______________________________ E-mail: __________________ Fax:___________________ Presented at an AF in the past? ______yes ______no AF de ______________ Acceptance of Nomination by Speaker or Artist I agree to have my name published on the Federation National Speakers and Programs List and understand this information will also be made available on the Federation Web site: Name: _______________________________________(Please Print) Signature: Date: Please return this form to: | ||
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