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Speakers Bureau Request

* Indicates required information
Your Name  * 
Your Organization/School (if applicable) 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Is this the location of the presentation? * 

If no - where will the location be? 
Primary Phone * 
Alternate/Cell Phone 
Email * 
Check All That Apply * 

If Other, please specify:

Check All That Apply * 

If you have multiple mixed groups, please check all that apply for all your groups. 
Expected attendance * 
Please add any additional information that you think will help us best serve your audience (e.g., demographics, previous knowledge of the topic, etc.) 
If you are requesting more than one presentation on one day -- or would like to schedule a series of presentations -- please elaborate in the "special instructions" box. 
DATE: First preference *  (mm/dd/yyyy)
DATE: Second preference  (mm/dd/yyyy)
DATE: Third preference  (mm/dd/yyyy)
Expected length of presentation * 
Anticipated start and end time * 
Unless otherwise requested, speakers will arrive 25-30 minutes prior to the specified start time of the presentation. 
Special Instructions  
You can also use this box to list additional times (i.e., if you are requesting more than one presentation on the same day.) 
What will the topic be? * 
Special Instructions 
Authentication * 

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Our presentations are free and almost always given by volunteers. While not required, please consider supporting our mission with a tax-deductible donation. Thank you!

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