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First Name

Last Name

Email Address

Phone Number

Organization/group hosting the event

Requested Date

Requested Time

Event Type Event Type In-Person Presentation Zoom/Skype Presentation Meeting Our Group Media Interview Professional Training Booth only

Event Address

Estimated Number in Attendance

Length of Presentation

Topic

Audience Description

Are you able to provide for travel expenses? Are you able to provide for travel expenses? Yes No

Are you able to provide an honorarium? Are you able to provide an honorarium? Yes No