Presentation Request Form

Marked * fields are required

Please fill out the form below to request a speaker from the Office of Emergency Management.

Only requests for presentations with an audience of at least 20 will be accommodated.

Organization Name: *

Contact Name: *

Mailing Address: *

Primary Phone: *

Fax:

Cell Phone:

Email Address:

Company/School/Organization for which the event is being planned (if different from above):

Topic (Please tell us what you would like our staff member to cover.): *

Type of Event (Clinic, Fundraising Dinner, Community Meeting, etc.) Please describe:

Date of Event: *

Start Time: *

End Time: *

Location of Event: *

How long will the staff member need to speak? *

What will the speaker be required to do? *

If other, please describe:

Audience Size: *

Target Audience *

Presentation Materials(Please check the boxes for materials that will be available at your location.):

Laptop Computer

Projector

Video Software

TV/Monitor

Projector Screen

Staff member must bring needed equipment