Northern California Regional Service Committee Travel Request Form

Please fill out as completely as possible and
click the "Submit by E-mail" button at the bottom.

Request Date:
Name:
Area
Name of Event:
Email:
Telephone:

Type of Travel Requested (Please check one):



Out of Region Activity or Event (not budgeted) Multi Area Activity or Event
Area Level Activity or Event Assistance at ASC or Sub-Committee
Other (Please specify)


Event / Activity Information (In order to help usbetter prepare, please include as much information as possible):

Event description and type of presentation requested:



Date of Event:
Time of Event:
Location of Event:
Contact Person:
Contact Phone Number:
Anticipated Size of Audience:
How much time will be afforded to the presenters for the presentation?:
Does the facility have a white wall or screen and lighting controls to allow for effective A/V Presentations?

YES NO

How Would You Generally Characterize the Audiences Overall Familiarity With the NA Service System?:



Novice (New GSR's, General Membership, etc.) Intermediate (Experienced ASC Trusted Servants)
Advanced (Serious Service Enthusiasts) A Mix of All of the Above




Thank you for your Travel Request Form Submission!

You should receive a confirmation reply shortly.