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* 1. Initial Contact Date

Date
Time

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* 2. Name

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* 3. Name of Company (If Applicable)

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* 4. Title

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* 5. Mailing Address

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* 6. Cell Phone

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* 7. Business Phone

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* 8. Email Address

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* 9. Type / Name of Event

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* 10. Purpose(s) of Event

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* 11. Location/Venue

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* 12. Proposed date/time of event

Date
Time

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* 13. Proposed number of Attendees

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* 14. Estimated Cost for Attendees (if applicable)

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* 15. Information and Description of Event

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* 16. Estimated cost to the 100 Club

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* 17. Reasons for cost

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* 18. 100 Club Responsibilities - Volunteers needed?  How many?

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* 19. 100 Club Information Table requested?

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* 20. 100 Club of Arizona Speaker requested? (If available)

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* 21. Percentage of proceeds to be donated to the 100 Club

0 100
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i We adjusted the number you entered based on the slider’s scale.

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* 22. How will the money be donated to the 100 Club (e.g. cash at event, check hand delivered after, check mailed after)

T