1. Speaker INFORMATION:

 a. Name of Speaker:
    

 b. Email Address:
            
 
 c. Business Phone: 
    
        
 d. Advance (if any) $:
    

2. CHAPTER INFORMATION

 a. Talk 1:
      i. Chapter name:
         

     ii. Chapter contact (name, email or phone):
         

    iii. Date of Event:
         

     iv. Expected Audience:
         

 b. Talk 2:
      i. Chapter name:
         

     ii. Chapter contact (name, email or phone):
         

    iii. Date of Event:
         

     iv. Expected Audience:
         
                 
 c. Talk 3:
      i. Chapter name:
         

     ii. Chapter contact (name, email or phone):
         

    iii. Date of Event:
         

     iv. Expected Audience:
         
                 
    

3. EXPENSES

 a. Transportation: $
    
        
 b. Subsistence: $
    
        
 c. Other: $
    
        
 d. Grand Total: $
      

4. EVENT INFORMATION

 a. Have the chapters agreed to adequately advertise your 
    talks?
     yes
     no

 b. Have the chapters agreed to cover local expenses? 
     yes
     no

 c. Are you satisfied with the coordination of the lecture tour? 
     yes
     no

5. COMMENTS

 a. additional comments for ACM HQ (limit 100 words)