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Questions marked with * are required.

Contact Name

Email Address

Organization

Address

City

ZIP Code

County

Telephone Number (with area code)

Preferred Presentation Date(s) and Time(s)

Preferred Presentation Date(s) and Time(s)
	Preferred Presentation Date(s) and Time(s) Preferred Presentation Date(s) and Time(s): Date Preferred Presentation Date(s) and Time(s): Time	Item weight

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Length of Speech

Est. Number of Attendees

May we publicize this event?

Desired Speech Topic

Presentation Location

Address

City/Town

ZIP/Postal Code

Presentation Site Phone Number(inc. area code)

Other Relevant Information

Which of the following items can you provide?

Projector

Projection Screen

Microphone

Other…

Consumer Assistance