Road Scholars Speaker Request Form

We appreciate your interest in the Road Scholars Speakers' Bureau program of Alabama Humanities Alliance (AHA)!
** Note: Please contact the speaker of your choice for confirmation of availability before submitting this form to AHA.
Contact information for each Road Scholar is found in the online catalog of speakers on the AHA web site: https://alabamahumanities.org/speakers/

Question Title

* 1. Name of organization sponsoring this Road Scholar presentation:

Question Title

* 2. Contact information for individual coordinating Road Scholar presentation:

Name *

Sponsoring organization address line 1: *

Address line 2

City: *

ZIP: *

County: *

Email address: *

Best phone number: *

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* 3. Alternative Contact Information

Name:

Email address:

Phone number:

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* 4. Name of Road Scholar you have confirmed for your event:

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* 5. Title of presentation to be made by confirmed Road Scholar:

Question Title

* 6. Date and time of Road Scholar presentation agreed upon by sponsor and speaker:

to be held on:

Date

Time

AM/PM

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* 7. Location of Road Scholar presentation agreed upon by sponsor and speaker:

Location (Include room name/number): *

Address: *

Address 2:

City: *

ZIP: *

Question Title

* 8. Audience Description

Expected size:

Description of audience: