Speaker Request Form
Name of Requesting Agency:
Date of Event:
Time of SSA Presentation
Length of SSA Presentation
Street Address
City
State
Posta/Zip Code
First Name
Last Name
Office Phone
Cell Phone
Example: (555) 555-5555
Fax
Email
Example: username@example.com
Purpose of meeting/convening: Please provide a detailed description of the event you would like the SSA to participate in. Please describe the nature of event, targeted audience and specific issues/concerns to be addressed.
What program areas or topic(s) would you like SSA staff to address?
How many attendees do you expect?
What type of collateral materials, if any, would you like the SSA to provide? Please be specific in the content area.
What is the presentation format (i.e. panel, individual speakers)?
Is parking available?
Is there additional information you think would be helpful to provide in preparation for this event?