Category I: General Public Program

This request form must be filled out completely - including signatures. There is a TWO application per calendar year limit for each organization and/or target audience. For first application include processing fee of $50 - or $75 for the following high use speakers: Jeff Barnes, Cherrie Beam-Callaway, Darrell Draper, Charlotte Endorf, Sue McLain, and Joan Wells. For second application, include processing fee of $100. Form and payment must be submitted at least 30 days before the program date.

Speaker Name (Required)

Program Title from Catalog (Required)

Program Date

Program Start Time

Please include the name of building as well as a street address.

Program Location (Required)

Maximum Occupancy (Required)

Have you confirmed date and time with speaker?

Your Organization's Name (Required)

Your Name (Required)

Your Phone (Required)

Your Email (Required)

Second Contact Name

Second Contact Phone

Second Contact Email

Home or organization address to which Humanities Nebraska should mail confirmation materials to you

Name (Required)

Organization (if applicable)

Mailing Address (Required)

City, State, Zip (Required)

Describe the audience you intend to reach (Required)

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Describe your goals/vision for this program (Required)

How do you plan to publicize (newspaper, radio, newsletters, flyers, social media)? (Required)

I ASSURE THAT MY ORGANIZATION WILL:

Guarantee that this program will be free and open to the public,
Acknowledge HN funding in all print materials, media interviews, and at the beginning of the presentation,
Hold this program in an accessible, public space with sufficient space to accommodate at least 25 people,
Promote and market this program,
Fulfill all publicity requiremtns (HN will send you a publicity packet after your request form is process),
Notify HN and the speaker immediately of any changes concerning the program (including cancellations),
Not use HN Speakers Bureau presentations as fundraisers, membership drives, or private gatherings, AND
Submit a final report within 10 days after the completion of the program.

I CONFIRM THAT:

The organization requesting this program is a not-for-profit entity.
I have read and understand the policies and procedures set forth by HN for this category.
I understand that failure to comply with the above requirements may jeopardize my organization's eligibility for future programs and/or funding.

Payment Form

Mail a Check
Online Payment

Please complete this form entirely before making your payment. A link to the online payment system is available at the end of this form.

Your Signature (Required)

Date

Oranization's Legal Representative Signature (if different)

Date

PLEASE MAKE CHECK OUT TO:
HUMANITIES NEBRASKA

If you have any questions please contact our office by calling 402-474-2131 or emailing info@humanitiesnebraska.org. We are more than happy to provide any necessary assistance!