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<a name="top"></a> <table border="0" cellpadding="0" cellspacing="0" width="455"> <tr> <td width="440" class="font2"> <p class="font2" align="justify">To invite a member of the Passages to Canada Employer Module to speak to your company/conference attendees, please complete the form below. We make an effort to match appropriate speakers with each group, so please provide as much detail as possible. </p> <br> <form name="submit_passages_event" action="request_event_act.asp" target="_top" method="POST" onsubmit="return validateme(this)"> <input type="hidden" name="Approval" value="0"> <table cellspacing="0" cellpadding="0" border="0" align="center" width="100%"> <tr valign="top"> <td align="right" valign="middle"> <p class="formelement"> <span class="italic">First name</span> </p> </td> <td align="left" valign="middle"> <p class="formelement"> <input name="FirstName" id="FirstName" type="text" size="20" style="width:150px" /></p> </td> </tr> <tr valign="top"> <td align="right" valign="middle"> <p class="formelement"> <span class="italic">Last name</span> </p> </td> <td align="left" valign="middle"> <p class="formelement"> <input name="LastName" id="LastName" type="text" size="20" style="width:150px"></p> </td> </tr> <tr valign="top"> <td align="right" valign="middle"> <p class="formelement"> <span class="formelement">Position:</span> </p> </td> <td align="left" valign="middle"> <p class="formelement"> <input name="Position" id="Position" type="text" size="20" style="width:150px" /> </p> </td> </tr> <tr valign="top"> <td align="right" valign="middle"> <p class="formelement"> <span class="italic">Name of Business/Organization:</span> </p> </td> <td align="left" valign="middle"> <p class="formelement"> <input name="Name_Business_Organization" id="Name_Business_Organization" type="text" size="20" style="width:150px" /> </p> </td> </tr> <tr valign="top"> <td align="right" valign="middle"> <p class="formelement"> <span class="italic">Business/Organization Address:</span> </p> </td> <td align="left" valign="middle"> <p class="formelement"> <input name="Business_Organization_Address" id="Business_Organization_Address" type="text" size="20" style="width:150px" /> </p> </td> </tr> <tr valign="top"> <td align="right" valign="middle"> <p class="formelement"> <span class="italic">Province:</span> </p> </td> <td align="left" valign="middle"> <p class="formelement"> <input name="Province" id="Province" type="text" size="20" style="width:150px" /> </p> </td> </tr> <tr valign="top"> <td align="right" valign="middle"> <p class="formelement"> <span class="italic">Postal Code:</span> </p> </td> <td align="left" valign="middle"> <p class="formelement"> <input name="PostalCode" id="PostalCode" type="text" size="20" style="width:150px" /> </p> </td> </tr> <tr valign="top"> <td align="right" valign="middle"> <p class="formelement"> <span class="italic">Telephone (where we can reach you during the day):</span> </p> </td> <td align="left" valign="middle"> <p class="formelement"> <input name="Telephone" id="Telephone" type="text" size="20" style="width:150px" /> </p> </td> </tr> <tr valign="top"> <td align="right" valign="middle"> <p class="formelement"> <span class="italic">Email</span> </p> </td> <td align="left" valign="middle"> <p class="formelement"> <input type="text" name="Email" id="Email" value="" size="20" style="width:150px"> </p> </td> </tr> <tr valign="top"> <td align="right" valign="top" colspan="2"> <p class="formelement"> <span class="italic">Audience Description</span> <TEXTAREA name="Audience_Description" id="Audience_Description" value="" size="20" style="width:250px"></textarea> </p> </td> </tr> <tr valign="top"> <td align="right" valign="middle"> <p class="formelement"> <span class="italic">Group Size</span> </p> </td> <td align="left" valign="middle"> <p class="formelement"> <input type="text" name="GroupSize" id="GroupSize" value="" size="20" style="width:150px"> </p> </td> </tr> <tr valign="top"> <td colspan="2" align="left" valign="middle"><br> <p class="formelement"> <span class="font2">Please indicate 3 convenient dates/times for the event:</span> </p> </td> </tr> <tr valign="top"> <td align="left" valign="middle"> <p class="formelement">1)Date: <input type="text" name="VisitDate" value="" size="20" style="width:150px"></p> </td> <td align="left" valign="middle" nowrap> <p class="formelement">Time: <input type="text" name="VisitTime" value="" size="20" style="width:120px"></p> </td> </tr> <tr valign="top"> <td align="left" valign="middle"> <p class="formelement">2)Date: <input type="text" name="VisitDate2" value="" size="20" style="width:150px"></p> </td> <td align="left" valign="middle"> <p class="formelement">Time: <input type="text" name="VisitTime2" value="" size="20" style="width:120px"></p> </td> </tr> <tr valign="top"> <td align="left" valign="middle" nowrap> <p class="formelement">3)Date: <input type="text" name="VisitDate3" value="" size="20" style="width:150px"></p> </td> <td align="left" valign="middle"> <p class="formelement">Time: <input type="text" name="VisitTime3" value="" size="20" style="width:120px"></p> </td> </tr> <tr valign="top"> <td colspan="2" align="left" valign="middle"><br> <p class="formelement"> <span class="italic">Additional information about the group</span> </p> </td> </tr> <tr> <td colspan="2" align="left" valign="middle"> <p class="formelement"> <TEXTAREA style="WIDTH: 400px" name=informationAboutGroup rows=10 cols=25></TEXTAREA> </p> </td> </tr> <tr valign="top"> <td colspan="2" align="left" valign="middle"><br> <input type="image" name="submit" src="images/main/submit_button.jpg" border="0"><br> <br> </td> </tr> </table> </form> </td> <td width="10"> </td> </tr> </table>
Passages to Canada receives funding from Canadian Heritage’s Human Rights Program. Click
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