Name *

First Name

Last Name

Phone

(###)

###

####

Club address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred / agreed date of talk *

MM

DD

YYYY

Time *

Hour

Minute

Second

AM PM

Talk option: *

Talk 1 - 90min

Talk 2 - 120 min

If in person, Please confirm that a projector with HDMI input and screen would be available for use.

Yes

Not required as online

Treasurer's name

First Name

Last Name

How did you hear about us?

Direct contact

Word of mouth

Via Google

Via social media

Via website

Other

Alternative date should it need

MM

DD

YYYY