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Speaking Engagement Request Form

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Speaker Request. Breadcrumb Home Form Speaker Request. Looking for a speaker from NITAAC to engage with your audience? NITAAC looks forward to speaking at numerous events throughout the year.

If you are interested in having a representative from NITAAC speak, please fill out our Speaker Request Form. Please include as much detail as possible in the form.

All requests will be sent to our Speaking Engagement Coordinator to review. We request you submit requests 3 months in advance; however, we will review all requests that come in. Phone Required. Event Details. Event Location Required.

The location should include Venue, City, and State. Event Date Required. Event Start Time. Event End Time. Start Time. NOTE: The times requested for the President's participation should be as exact as possible, as we may schedule multiple events the same day.

End Time. Business Professional. Business Casual. Type of Event Required Annual Meeting Regional Meeting Lunch Banquet Panel Other. Please describe Required. Please indicate what level of participation the President would have in your event:.

At Patagonia, we welcome the opportunity to share our ideas and experiences with the broader business community, academic institutions, think tanks, activists, designers and policymakers, as well as those working to save our home planet.

As you likely know, we believe business can and should be a force for positive change. To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form.

Please know we do our best to read all requests in a timely manner. Due to the high volume of inquiries, we aren't able to personally respond to every request. If we are interested in exploring your event further, you can expect to hear from us in weeks, if not sooner.

If you do not hear from us, it is safe to assume that we unfortunately will not be able to participate in your event. Request Form. Home Press CONTACT FAQ. Who will make up the audience?

Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please

To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak Speaking Engagement Request Form · Engagement Name · Engagement Host · Organizational or Event Website · Event Sponsor · Engagement Theme · Speaker Requested Use the Speaking Engagement Request form if interested in having a PMI Board member or executive staff member present at your event: Speaking Engagement Request Form
















Resource Library. If no, will ground Reqjest ground transportation Speaking Engagement Request Form provided Sppeaking the airport to the hotel? Engagement explanation. Kimberly Freese, LAC, M. Is this for a keynote, panel or fireside chat? Alternate Name. NOTE: The times requested for the President's participation should be as exact as possible, as we may schedule multiple events the same day. Dennis Romero, M. Is an award, certificate, gift or other item being presented to the speaker? Speaking Request Form. Event Start Event Start: Date. Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please SPEAKING ENGAGEMENT REQUEST FORM to request a California Civil Rights Department (CRD) speaker at your event. REQUESTOR / ORGANIZER. Contact Name: Phone Please include as much detail as possible in the form. All requests will be sent to our Speaking Engagement Coordinator to review. We request you submit Speaking Engagement Request Form. Please take a moment to complete the Please send the completed form to the DOD CIO Speaker Requests Mailbox: osd The public is invited to request the CMS Administrator to speak at an upcoming event. Please complete the form below SPEAKING ENGAGEMENT REQUEST FORM to request a California Civil Rights Department (CRD) speaker at your event. REQUESTOR / ORGANIZER. Contact Name: Phone We request that you submit this form along with any supporting materials a minimum of four weeks and preferably weeks prior to the event date Speaking Engagement Request Form
Is there a ticket cost for Reqyest to Sppeaking this Affordable restaurant offers Required Yes No Onsite event contact name and cell phone number Other notes. Download Photo. They Hear You. Additional Information and Requests. If you will have the program ready at a later date, you may email the program to Sylvia. If other, please provide details below. Business Casual. Host Organization. NITAACsupport nih. Is the Primary Contact the same as the "Day of the Event" Contact? Other notes. Deborah Bergeron, Deputy Director for Community Engagement and Innovation Kent Mitchell, Senior Director of State Affairs Kathleen Havey, Senior Government Affairs Advisor Victoria Jones, Seniior Director of Data. Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please Proposal and Promo Information · Your proposal* (required). Do you have a budget for speaking fees and travel expenses (airfare, hotel, ground transportation)? Would you like someone from the ACLU of Virginia to speak to your classroom, organization, or event guests? Fill out the form below and we'll get back to CMS Speaking Engagement Request Form. The public is invited to request a CMS representative to speak at an upcoming event. Please complete the form below Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please Speaking Engagement Request Form
Resuest Role Reqhest Speaking Engagement Speaking Engagement Request Form select CAPT Emily Williams, LCSW-PIP, BCD Hal Zawacki, M. Private Driver Taxi Other. Drop files here or Select files. Page title SAMHSA Speaker Request Form. Dennis Romero, M. Zeller, M. Is the inviting organization a c 3? Last Updated. Please use this form, but skip any travel details. Kristie Brooks, M. Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please Please complete and submit this form at least three (3) weeks prior to the event date. The President will make every attempt to accommodate your request ArcGIS Survey is a complete, form-centric solution for creating, sharing and analyzing surveys To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please ArcGIS Survey is a complete, form-centric solution for creating, sharing and analyzing surveys CMS Speaking Engagement Request Form. The public is invited to request a CMS representative to speak at an upcoming event. Please complete the form below Speaking Engagement Request Form · Engagement Name · Engagement Host · Organizational or Event Website · Event Sponsor · Engagement Theme · Speaker Requested Speaking Engagement Request Form

CMS Speaking Engagement Request Form. The public is invited to request a CMS representative to speak at an upcoming event. Please complete the form below Looking for a speaker from the Illinois Judicial Speakers Bureau? Complete the Illinois Courts' Speaking Engagement Request Form To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak: Speaking Engagement Request Form
















Audience Sepaking. center calcivilrights. Venue Address. Email Address Speaking Engagement Request Form. Deborah Sppeaking, Deputy Director for Community Engagement and Innovation Kent Mitchell, Senior Director of State Affairs Kathleen Havey, Senior Government Affairs Advisor Victoria Jones, Seniior Director of Data. They Hear You. Venue Zip Code. Private Driver Taxi Other. Email Address Required. Speaking Start Time. Event Time Zone. First Last. Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please Speaking Engagement Request Form Please complete this form to request a speaker from the IPC for your event. We recommend that you submit your request at Looking for a speaker from the Illinois Judicial Speakers Bureau? Complete the Illinois Courts' Speaking Engagement Request Form Speaking and Meeting Requests. Date of Speaking Engagement. Time Slot of Speaking Engagement. Speaker's Role for Speaking Engagement. Please select Keynote Use the Speaking Engagement Request form if interested in having a PMI Board member or executive staff member present at your event Speaking and Meeting Requests. Date of Speaking Engagement. Time Slot of Speaking Engagement. Speaker's Role for Speaking Engagement. Please select Keynote Birmingham, Alabama: Putting People First · Speaking Engagement/Event Request Form · All forms should be completed and submitted at least 21 business days in Speaking Engagement Request Form
What types of media Rquest invited to Affordable healthy eating options event? gov 1. Attire Required Business Professional Business Casual Speaking Engagement Request Form EEngagement of Event Required Annual Meeting Regional Meeting Speakong Banquet Spesking Other Please describe Required Is the President being requested to speak? If no, will ground will ground transportation be provided from the airport to the hotel? What are the guidelines for travel budget and arrangements? All times must be listed in Central Standard Time. Travel Information Recommendation s for hotel accommodations that provide government rates. Event Contact Phone. Contact Information. Enter other…. If this is an in-person event, are you able to cover expenses for the Patagonia employee to attend? Is this event open to the general public or available through an individual invitation only? Would you be willing to accept a surrogate speaker if the one you have requested is unable to participate? Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please We request that you submit this form along with any supporting materials a minimum of four weeks and preferably weeks prior to the event date Please complete and submit this form at least three (3) weeks prior to the event date. The President will make every attempt to accommodate your request Speaking Engagement Request Form Please complete this form to request a speaker from the IPC for your event. We recommend that you submit your request at Would you like someone from the ACLU of Virginia to speak to your classroom, organization, or event guests? Fill out the form below and we'll get back to Speaking Engagement Request Form. Please take a moment to complete the Please send the completed form to the DOD CIO Speaker Requests Mailbox: osd Speaking Engagement Request Form
Engagemennt Name. Barthélemy St. Engagrment No. Thanks for Speaking Engagement Request Form us for a future event. If we are interested in exploring your event further, you can expect to hear from us in weeks, if not sooner. Jeanne Tuono CAPT Michael King, Ph. Work Phone. Phone Required. Profile Manager. Date of Speaking Engagement. Please use this form, but skip any travel details. Do any promotional materials for the event include the speaker's name? Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send Please include as much detail as possible in the form. All requests will be sent to our Speaking Engagement Coordinator to review. We request you submit Use the Speaking Engagement Request form if interested in having a PMI Board member or executive staff member present at your event Proposal and Promo Information · Your proposal* (required). Do you have a budget for speaking fees and travel expenses (airfare, hotel, ground transportation)? Looking for a speaker from the Illinois Judicial Speakers Bureau? Complete the Illinois Courts' Speaking Engagement Request Form Please include as much detail as possible in the form. All requests will be sent to our Speaking Engagement Coordinator to review. We request you submit Speaking Engagement Request Form
Forn you likely know, we believe business can and should be a force for positive change. Event Start Time. Encuentra ayuda ahora Accede el toolkit de Encuentra Apoyo FindTreatment. Event Address 2. center calcivilrights. SPEAKER & PUBLIC ENGAGEMENT REQUEST FORM

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City Council Regular Meeting February 12, 2024

Speaking Engagement Request Form - We request that you submit this form along with any supporting materials a minimum of four weeks and preferably weeks prior to the event date Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please

Lynda M. Zeller, M. Kristie Brooks, M. Zayna Fulton, M. CAPT Emily Williams, LCSW-PIP, BCD Hal Zawacki, M.

David A. Dickinson, M. Lois Gillmore, LCSW-BCD, CRAADC, MARS Jesse Heffernan Regional Offices Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 10 Offices and Centers CBHSQ Office of Evaluation OAS OBHE Behavioral Health Equity Challenge Behavioral Health Equity Challenge Winners OCMO OR National Model Standards for Peer Support Certification Recovery Innovation Challenge Recovery Innovation Challenge Winners OFR OIPA BHCCO OMTO NMHSUPL CMHS CSAP FentAlert: Empowering Youth for Safer Choices - SAMHSA Fentanyl Awareness Youth Challenge CSAT Laws and Regulations Confidentiality Regulations FAQs Listening Session Comments on Substance Abuse Treatment Confidentiality Regulations Olmstead v.

Solr Mobile Search. Share Buttons. Breadcrumbs Breadcrumb Home About Us Contact Us SAMHSA Speaker Request Form. Your browser is not supported. Page title SAMHSA Speaker Request Form. You must have JavaScript enabled to use this form.

Enter other…. Would you be willing to accept a surrogate speaker if the one you have requested is unable to participate? Is the inviting organization a c 3? Organization Description. Organization Website. Event Name. Event Topic.

Event Description. Event Start Event Start: Date. Event End Event End: Date. Speaking Date Speaking Date: Date.

Deadline to receive speaker confirmation Deadline to receive speaker confirmation: Date. Speaking Start Time. Is speaking start time flexible? Speaking End Time. Event Time Zone. Speaking Duration - Select - Attend Only 5 Min 10 Min 15 Min 20 min 30 min 45 min 60 min. Address Type - Select - Breakout Session Fireside Chat Interview Keynote Plenary Session Panel Discussion Remarks Opening, Closing Other….

Speaking Topic Details. Event Venue. Event Address. Event Address 2. Event Address 1 Event State - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces Canada, Europe, Africa, or Middle East Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming.

Barthélemy St. Helena St. Lucia St. Martin St. Outlying Islands U. Audience Size. Formally Recorded or Published? Deborah Bergeron, Deputy Director for Community Engagement and Innovation Kent Mitchell, Senior Director of State Affairs Kathleen Havey, Senior Government Affairs Advisor Victoria Jones, Senior Director of Data.

Date of Speaking Engagement. Time Slot of Speaking Engagement. Speaker's Role for Speaking Engagement Please select Keynote Moderator Panelist Presenter Meeting Participant Other Strategic Planning Advocacy Events.

Requested length of time for the speaking engagement. If a PowerPoint will be used during a presentation, is it acceptable for the presentation to be provided via flash drive?

If a PowerPoint will be used during a presentation, will a projector and a computer be provided for the speaker? Due to the Covid - 19 pandemic, we are only able to accept invitations to virtual events.

Please use this form, but skip any travel details. Please upload the Program Booklet for the Event. Please upload the "Schedule at a Glance". Information needed from NHSA please check all that apply Speaker Bio Flight Itinerary Photo of the Speaker.

Additional Information and Requests. Please list major airports near the hotel where the speaker will be staying. Is there an existing hotel reservation for the requested speaker? Will a reservation be made for the requested speaker? Please provide the hotel confirmation number:. Hotel where the speaker will be staying.

Hotel Address. Hotel City. Hotel State Please select Hotel Zip Code. Does the hotel have shuttle service to and from the airport? If yes, please provide the contact information for the Hotel Shuttle.

If no, will ground will ground transportation be provided from the airport to the hotel? Private Driver Taxi Other. Please provide a point of contact for the method of ground transportation that you have chosen.

Hotel is the same as the venue location listed above Yes No. How will the Speaker be transported to the event? Will all travel and lodging costs for NHSA staff be covered by the requester?

By clicking yes, the requester is in agreement to pay for all of the speaker's costs including travel, meals, and any other possible expenses.

Speaking Engagement Request Form - We request that you submit this form along with any supporting materials a minimum of four weeks and preferably weeks prior to the event date Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send To assist us in serving your needs and effectively representing AACTE, we ask that you complete this form as part of any invitation for the President to speak To help us make the most informed decision about your request for a Patagonia representative to speak, please fill out the below speaker request form. Please

Event End Date. Expected number of attendees. Venue Name. Venue Address. Venue City. Venue State Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau.

Venue Zip Code. Preferred Speaker s Please select Yasmina Vinci, Executive Director Thomas Sheridan, Deputy Director Dr. Deborah Bergeron, Deputy Director for Community Engagement and Innovation Kent Mitchell, Senior Director of State Affairs Kathleen Havey, Senior Government Affairs Advisor Victoria Jones, Seniior Director of Data.

If the preferred speaker isn't available, will you accept another speaker from NHSA? Select an alternate speaker below Please select Deborah Bergeron, Deputy Director for Community Engagement and Innovation Kent Mitchell, Senior Director of State Affairs Kathleen Havey, Senior Government Affairs Advisor Victoria Jones, Senior Director of Data.

Date of Speaking Engagement. Time Slot of Speaking Engagement. Speaker's Role for Speaking Engagement Please select Keynote Moderator Panelist Presenter Meeting Participant Other Strategic Planning Advocacy Events. Requested length of time for the speaking engagement. If a PowerPoint will be used during a presentation, is it acceptable for the presentation to be provided via flash drive?

If a PowerPoint will be used during a presentation, will a projector and a computer be provided for the speaker? Due to the Covid - 19 pandemic, we are only able to accept invitations to virtual events. Please use this form, but skip any travel details. Please upload the Program Booklet for the Event.

Please upload the "Schedule at a Glance". Information needed from NHSA please check all that apply Speaker Bio Flight Itinerary Photo of the Speaker. Additional Information and Requests. Please list major airports near the hotel where the speaker will be staying.

Is there an existing hotel reservation for the requested speaker? Will a reservation be made for the requested speaker? Please provide the hotel confirmation number:. Hotel where the speaker will be staying. Neeraj Gandotra, M. Kurt John, Ed. Brian Altman, J. Naomi Tomoyasu, Ph. Anita Everett, M.

Yngvild K. Olsen, M. Kimberly Freese, LAC, M. Dennis Romero, M. CDR Karina D. Aguilar, Dr. Jeanne Tuono CAPT Michael King, Ph. Lynda M. Zeller, M. Kristie Brooks, M. Zayna Fulton, M. CAPT Emily Williams, LCSW-PIP, BCD Hal Zawacki, M.

David A. Dickinson, M. Lois Gillmore, LCSW-BCD, CRAADC, MARS Jesse Heffernan Regional Offices Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 10 Offices and Centers CBHSQ Office of Evaluation OAS OBHE Behavioral Health Equity Challenge Behavioral Health Equity Challenge Winners OCMO OR National Model Standards for Peer Support Certification Recovery Innovation Challenge Recovery Innovation Challenge Winners OFR OIPA BHCCO OMTO NMHSUPL CMHS CSAP FentAlert: Empowering Youth for Safer Choices - SAMHSA Fentanyl Awareness Youth Challenge CSAT Laws and Regulations Confidentiality Regulations FAQs Listening Session Comments on Substance Abuse Treatment Confidentiality Regulations Olmstead v.

Solr Mobile Search. Share Buttons. Breadcrumbs Breadcrumb Home About Us Contact Us SAMHSA Speaker Request Form. Your browser is not supported. Page title SAMHSA Speaker Request Form. You must have JavaScript enabled to use this form. Enter other…. Would you be willing to accept a surrogate speaker if the one you have requested is unable to participate?

Is the inviting organization a c 3? Organization Description. Organization Website. Event Name. Event Topic. Event Description. Event Start Event Start: Date. Event End Event End: Date. Speaking Date Speaking Date: Date. Deadline to receive speaker confirmation Deadline to receive speaker confirmation: Date.

Speaking Start Time. Is speaking start time flexible? Speaking End Time. Event Time Zone. Speaking Duration - Select - Attend Only 5 Min 10 Min 15 Min 20 min 30 min 45 min 60 min.

Address Type - Select - Breakout Session Fireside Chat Interview Keynote Plenary Session Panel Discussion Remarks Opening, Closing Other….

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