Speaker Request Form

* Required Field

* Background Information
Requested Speaker(s)

Subject Matter to be Discussed
Host or Sponsor of the Event
Speaking Engagement Date		(MM/DD/YYYY)
Location of the Event/ Speaking Engagement
Background of Attendees (e.g., Federal employees, private practitioners, corporate counsel, lobbyists etc.)
Anticipated Number of Attendees
Anticipated Number of federal employees attending
Event Details: (If the speaking engagement is part of a larger event please list)
Event Start Date		(MM/DD/YYYY)
Event End Date		(MM/DD/YYYY)
Name of the Event
* If travel expense are being offered, please include the nature of the expense. (e.g. Ground, Airline, Hotel, Meals)
		Estimated Value:
* State whether the event is open to the public
Yes No If Yes, is there any charge to the public?
* Is the event open to the press and/or recorded?
Yes No
* General Contact Information
Point of Contact
Organization Name
Title
Address
Phone Number		(XXX-XXX-XXXX)
Email Address

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Last Modified: 10/07/2012 20:03:41