Southcentral Foundation Nuka Request form

For additional information:
Southcentral Foundation
Nuka Institute
4175 Tudor Centre Drive
Anchorage, AK 99508
SCFNUKAInstitute@scf.cc

Southcentral Foundation Nuka Request Form

A. Tell us about your organization:
Organization Name	Type of Organization
Address	City	State	Zip
How did you hear about us?	If other, please specify
Tell us about your organization (What kind of organization? How many employees? When and by who was it founded?)

B. Requestor Information:
Name	Title
Phone Number	Email	Fax

C. Please select and complete all that apply to request:
Speaker, Presentation and/or Consulting Request
Topic of Interest	Additional topics of interest
Requested Speaker	Please describe what you are trying to achieve
Type of Event	Please describe what you are trying to achieve
Location of Event	Date(s) of Event
Number of Attendees Anticipated
Description of Attendees
If your event has a website, please provide the address
Information Requested
Topic of Interest		Additional topics of interest
Please describe your request	Deadline to receive information
Site Visit to Southcentral Foundation Requested
Topic of Interest	Additional topics of interest
Describe what you are trying to achieve while visiting us
Number of participants in site visit	Description of site visit attendees
Date(s) of site visit
If this is your first time contacting us please write a letter to our CEO Katherine Gottlieb introducing yourself and your request

D. Expenses
Describe expenses that are paid for by your organization

NOTE: Southcentral Foundation has standard speaker, presentation, consultation, and site visit fees.