Organization InformationOrganization*Contact Person* First Last Phone Number*Email* Address* Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Speaking LocationSpecial InstructionsHow did you hear about the Speakers Bureau?*Venue DescriptionPlease describe to assist speaker's preparationType of RoomClassroomHallTheaterGymnasiumSize of RoomSmallMediumLargeExtra LargeEquipment Available (Check all that apply) White Board Blackboard SmartBoard Flip-charts PowerPoint Projector Computer Microphone/Sound System Information About Presentation and ParticipantsDate Time : HH MM AM PM Number or Participants10-3031-6061-100100+Age RangePlease describe the participants' general knowledge of HIV/AIDS issues:*MinimalMediumExtensiveDetailsContent of Presentation: Briefly describe the educational goal for the presentation. What themes or topics would you like presented?*Speaker CostPlease note - due to expense of administering the Speakers Bureau and honorariums paid to Speakers, Cascade AIDS Project's standard fees for a speaking engagement of 1 to 3 hours are as follows: 1 Speaker: $100 2 Speakers: $150 3 Speakers: $200If your organization is unable to pay for the speaker request, simply check the box below asking for a subsidized talk - and we will do our best to accommodate you. Subsidized Talk This iframe contains the logic required to handle Ajax powered Gravity Forms.