Lyceum Request Form **PLEASE NOTE COMMITTEE MEETS INFREQUENTLY AND MAY APPROVE REQUEST FOLLOWING EVENT. Requesting Department or Organization * Contact Person * Phone Number * Email Address * Building/Office No. Name of Department Head * Department Head Phone Number * Department Head Email Address * Speaker's Name * Speaker's Address * Speaker's SSN or Agency's TIN * If the Above Number is the Agency's TIN, Please Provide the Name of the Agency Lecture Topic * Date of Event * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Time of Event * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Location of Event * How Was This Speaker Decided Upon? * Amount Requested * Have Matching Funds Been Secured? * Yes No Amount Secured * If Matching Funds Have Been Secured, From What Sources Have They Been Secured? Please Explain in Detail What the Requested Amount is Supposed to Cover (NOTE: These funds cannot pay for food or travel) * Leave this field blank
