Speaker Request Form

Name of Requesting Agency:
Date of Event: 12/12/2011
Please note: All speaker requests forms should be submitted 30 days in advance of the requested date.
Time Time of SSA Presentation
Length of SSA Presentation:
Address
Street Address City State Postal / Zip Code

Agency Contact Person First Name Last Name
Office Phone 510-271-5555
Cell Phone 510-271-4444
Fax 510-271-3333
Email john_doe@acgov.org
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?

Leave this field empty