2011 NGWREF Darcy Lecture Series
Request Form
Please fill out the following information and press the submit button.

Deadline for submissions is October 15, 2010.
*Proposed host site
*Institute or company name
*Contact person at site
*Mailing address 1
Mailing address 2
*City
*State
*Zip or postal code
*Country
*Phone number
Fax number
*E-mail
*Desired date for lecture
Optional dates

* Required Data.

I have the authority in which to represent the above-stated company/organization/university.

I understand that if chosen to host the Darcy Lecture Series, my company/organization/university is willing to provide the speaker the following:

   • Housing for the lecturer (usually the night before the lecture and the night of the lecture)
   • Meals during the lecturer's stay
   • Any audio/visual equipment that the speaker needs.
I agree to the above statements.   Yes.   No.
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