1. Contact Information

Name:	Title*	First*	Last*
	Mr. Ms. Mrs. Miss Dr.
E-mail*:
Address 1*:
Address 2:
City/State/Zip:	City*	State*	Zip*
		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Phone*:	() -
Gender*:	Male Female
Date of Birth:	Month	Day	Year
	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908

*2. What is your organization's name?

*3. Who will be the Onsite Contact for the event?

*4. What is the Onsite Contact's phone number?
() -

*5. What is the Onsite Contact's e-mail address?

6. What is the organization's web address?

*7. What is your preferred event date and time?
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2008 2009     Hour 0 1 2 3 4 5 6 7 8 9 10 11 12 Minute 00 05 10 15 20 25 30 35 40 45 50 55 AM/PM AM PM

*8. Where will the event take place?

*9. What county will the event take place?
Bibb Blount Calhoun Chambers Cherokee Chilton Clay Cleburne Colbert Coosa Cullman DeKalb Etowah Fayette Franklin Greene Hale Jackson Jefferson Lamar Lauderdale Lawrence Limestone Madison Marion Marshall Morgan Perry Pickens Randolph St. Clair Shelby Sumter Talladega Tallapoosa Tuscaloosa Walker Winston

*10. Please provide directions to the event?

(Maximum response 250 characters)

*11. Please provide specific check-in procedures for the speaker when the arrive at the event?

(Maximum response 250 characters)

12. Parking
*Is parking provided?
Yes No

If parking is provided, please give the exact location of the parking location.

(Maximum response 250 characters)

If parking is not provided, please give the location of the nearest parking location.

(Maximum response 250 characters)

*13. How many participants are expected to attend the event?

*14. Please describe the type and format of the event. (eg. lunch-and-learn, group discussion, health fair, etc.)

(Maximum response 250 characters)

*15. Will there be additional speakers?
Yes No

*16. Please describe the expected audience. (eg. age, race, religion, breast cancer survivors, et.c)

(Maximum response 250 characters)

*17. How should the speaker dress? (eg. business casual, suit, etc.)

*18. Has your organization ever formed a team for the Komen Birmingham Race for the Cure?
Yes No

*19. Would your organization like to be added to our Race for the Cure teams mailing list?
Yes No

*20. How did you find out we offer speakers and participate at health fairs?