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 | | PROGRAM AGREEMENT
Roberta Roth, CSW agrees to provide services for the scheduled date (s) and program listed below.
___________________________________of____________________________(client) agrees to
Accept the program listed in accordance with the terms and conditions of this agreement.
Program Title: _____________________________________________Program Speaker: __________________________________
Program Date: _______________________________Program Day: ____________________Program Time:_______________
Program Description: --- Keynote ___On-Site ---Training Conference
Program Contact:____________________________________________________Title: ____________________________________
Street Address: _____________________________________________________________________________________________
City:___________________________________________________State: _________________Zip: _________________________
Phone: ____________________________ _Fax: _________________________________Email: __________________________
To ensure the invoice and payments are made within terms, please provide us with the following information:
Accounts Payable Contact: ______________________________________________ ____Phone: ____________________
Mailing Address: _____________________________________________________________________________________
City: _______________________________________________State: ___________________Zip:________________________
__________________________________________________________________
Program Honorarium: ____________________________ Due Date: ____________________________________
Tax ID Number: 066-40-7453 Check Payable To: Roberta Roth
Your signature on this agreement acknowledges that payment for the entire program honorarium will be given to the speaker the day of the program. An invoice for the program honorarium will be sent 30 days prior to the program date. If you would like to prepay the honorarium, please mail your check to Roberta Roth, P.O. Box 1517, Scarsdale, NY 10583.
Payments not received by _________________________________________will result in a $500.00 late fee. In addition, the client agrees to pay all expenses related to the execution of the program in accordance with the terms of conditions of Roberta Roth expense reimbursement. An invoice for expense reimbursement will be sent upon completion of the program. A $100 late fee will be assessed if payment for expense reimbursement is not received within 30 days of the program date. Cancellation by the client within 30 days of the scheduled date (s) will result in a $1,500 cancellation fee. Should acts of God prohibit the execution of this program, it is understood that Roberta Roth will not be held liable. Video or audio taping of the program for any reason is prohibited without written consent from Roberta Roth.
_________________________________________________________ _________________________________
Authorized Client Representative Date
_________________________________________________________ ______________________________
Roberta Roth, CSW Date
Please keep a copy of this Program Agreement for your records. Please mail the original copy of this Program Agreement to:
Roberta Roth, CSW, P.O. Box 1517, Scarsdale, NY 10583
Phone: 1-877-771-5437 / Fax (914)941-5753 / WEB RobertaRoth.com
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