Form

Please provide the following information about the conference, event, or program you are intersted in hosting. Professional Education and Outreach staff will then contact you about your arrangements.

Host Orginzation *

Is host organization tax exempt? *

Yes No

Contact Name *

Contact Email *

Contact Phone Number *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Are you the billing contact? *

Yes No

If you are not the billing contact, please provide billing contact's information below:

Full Name

First Name Last Name

E-mail

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please describe the conference, event, or program you plan to host: *

Please indicate your prefered date(s) for your conference, event, or program.

First date choice *

- Month - Day Year

Second date choice

- Month - Day Year

Third date choice

- Month - Day Year

Start Time *

End Time *

How many do you expect to attend? *

Will you be charging an attendance or registration fee? *

Yes No

What kind of room setup do you prefer? *

Please indicate what kind of technology or media services you require: *

Projector and screen Computer lab Polycom or teleconferencing On site media personnel None, our program will not use any technology or media

What services are you interested in acquiring? *

Space reservation on the Kansas State Polytechnic campus Catering Technology or media assistance Registration management Marketing and communication Financial management Speaker and programming arrangements Course or flight instruction

By typing your name here, you affirm that you understand and will abide by the Kansas State Polytechnic General Building Policies. *