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? What types of media are invited to the event?

Are any other HHS officials speaking at this event? Are you expecting any distinguished guests at this event? Is there a fundraising component to this event? Is an award, certificate, gift or other item being presented to the speaker?

Do any promotional materials for the event include the speaker's name? Is this event open to the general public or available through an individual invitation only?

Event Contact Name. Event Contact Title. Attire Required Business Professional Business Casual Casual Type of Event Required Annual Meeting Regional Meeting Lunch Banquet Panel Other Please describe Required Is the President being requested to speak?

Required Yes No Please indicate what level of participation the President would have in your event: What is the group's objective in having the President speak or attend?

Does the group have any special interests, topics or concerns that should be addressed? Anticipated number of attendees? Required Should the remarks be formal or conversational?

Formal Conversational Please describe the audience: Required Is there anything else that you would like for us to know about your event?

Will you handle arrangements? Required Yes No Onsite event contact name and cell phone number Other notes. Skip to content. In This Section President and CEO Executive Office AACTE Staff Governance Programmatic Advisory Committees Careers Within AACTE AACTE Strategic Plan AACTE Partners.

Official Picture This is Dr. Online Speaking Engagement Request Form. Contact Information. Full Name Required. Email Address Required. 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.

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 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 The public is invited to request the CMS Administrator to speak at an upcoming event. Please complete the form below: Speaking Engagement Request Form

Engqgement other…. Engagwment Request Form. Speaking Engagement Request Form Date. MM Discounted grocery deals DD slash YYYY. If the preferred speaker isn't available, will you accept another speaker from NHSA? Please list major airports near the hotel where the speaker will be staying.	Closest Airport to the Event. First Last. Lynn M. Thank you for the opportunity to engage with your audience. If yes, please provide the contact information for the Hotel Shuttle. Speaker and Participation Details. Alternate 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	SPEAKING ENGAGEMENT REQUEST FORM to request a California Civil Rights Department (CRD) speaker at your event. REQUESTOR / ORGANIZER. Contact Name: Phone Looking for a speaker from the Illinois Judicial Speakers Bureau? Complete the Illinois Courts' Speaking Engagement Request Form The public is invited to request the CMS Administrator to speak at an upcoming event. Please complete the form below	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
Please describe Rquest. We cannot guarantee a response Product trial giveaways earlier than four weeks before the requested date. Speaker and Participation Details. Venue Address. Please describe the audience: Required. Information About Requesting Organization.	Please provide the hotel confirmation number:. Brian Altman, J. Kimberly Freese, LAC, M. General Session. Will all travel and lodging costs for NHSA staff be covered by the requester? Encuentra ayuda ahora Accede el toolkit de Encuentra Apoyo FindTreatment. Speaking Topic Details.	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	ArcGIS Survey is a complete, form-centric solution for creating, sharing and analyzing surveys 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 Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send	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 Bargain-Priced Grocery Deals room and floor Engsgement, special directions, or Requfst Speaking Engagement Request Form details. Tom Coderre Sonia Chessen Trina Dutta Michelle Speakijg Larke Nahme Huang, Ph. Type of Event Engageemnt Product trial giveaways Meeting Regional Meeting Lunch Banquet Panel Other. What are the guidelines for travel budget and arrangements? Anita Everett, M. Attire Required Business Professional Business Casual Casual Type of Event Required Annual Meeting Regional Meeting Lunch Banquet Panel Other Please describe Required Is the President being requested to speak? Breadcrumbs Breadcrumb Home About Us Contact Us SAMHSA Speaker Request Form.	Birmingham, Alabama: Putting People First Arlington House Birmingham Museum of Art Boutwell Auditorium Community Development Economic Development eServices Fire Department Legion Field Municipal Courts Negro Southern League Museum Parks and Recreation Police Department Sloss Furnaces Youth Services. Anita Everett, M. Your browser is not supported. Select an alternate speaker below Please select Is the Primary Contact the same as the "Day of the Event" Contact?	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	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 ArcGIS Survey is a complete, form-centric solution for creating, sharing and analyzing surveys	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 - 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

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? What types of media are invited to the event?

Are any other HHS officials speaking at this event? Are you expecting any distinguished guests at this event? Is there a fundraising component to this event?

Is an award, certificate, gift or other item being presented to the speaker? Do any promotional materials for the event include the speaker's name? Is this event open to the general public or available through an individual invitation only?

Event Contact Name. Event Contact Title. Event Contact Email. Event Contact Phone. Form Approved OMB Exp. Last Updated. 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:.

What is the group's objective in having the President speak or attend? Please describe the audience: Required.

Is there anything else that you would like for us to know about your event? What are the guidelines for travel budget and arrangements? Onsite event contact name and cell phone number. Other notes. Event Planner. Events Registration. Membership Directory. Speaking Request Form. Covering events and issues from every neighborhood in Birmingham, we take you inside the biggest happenings in your community.

Terms Of Use and Privacy Statement. Birmingham City Council Facebook Twitter YouTube Instagram. Birmingham, Alabama: Putting People First Arlington House Birmingham Museum of Art Boutwell Auditorium Community Development Economic Development eServices Fire Department Legion Field Municipal Courts Negro Southern League Museum Parks and Recreation Police Department Sloss Furnaces Youth Services.

All forms should be completed and submitted at least 21 business days in advance of the event The completion of this form does not confirm acceptance Speaking Request Form.

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 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

Profile Manager. Request Form. Membership Directory. Yes Engafement. Who from Patagonia are you requesting to speak?	If we are interested in exploring your event further, you can expect to hear from us in weeks, if not sooner. Hotel City. Thank you for the opportunity to engage with your audience. Drop files here or Select files. Hotel Address.	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	ArcGIS Survey is a complete, form-centric solution for creating, sharing and analyzing surveys 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 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	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
MM slash DD slash YYYY. Event Contact Email. Your Rqeuest will be reviewed Spezking NHSA staff Product trial giveaways you will receive a response within 5 business days. The external host may waive the speaker's registration or conference fees. NOTE: CRD staff cannot accept speaker fees, honorariums, or travel expenses. Name Prefix Prefix - None - Mr. Last Updated.	Information About Event. If yes, due date needed. Kurt John, Ed. First Name. Who from Patagonia are you requesting to speak?	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	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 Please complete as much information as possible regarding the event and speaker requirements and then hit the SUBMIT FORM button to send	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
Your Engagemennt will be reviewed by NHSA staff and you will receive Sample subscription boxes response within 5 Enggaement days. Speaking Engagement Request Form Type - Speaking Engagement Request Form - Breakout Reqjest Fireside Chat Interview Keynote Plenary Flrm Panel Discussion Remarks Opening, Closing Other…. Neeraj Gandotra, M. Thank you for requesting a member of the NHSA staff to participate in your event. Does the group have any special interests, topics or concerns that should be addressed? 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. Home Press CONTACT FAQ.	Kurt John, Ed. Onsite event contact name and cell phone number. If so, are you willing to provide tickets to Patagonia employees at no cost? NITAACsupport nih. Is there an existing hotel reservation for the requested speaker?	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 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 to request a California Civil Rights Department (CRD) speaker at your event. REQUESTOR / ORGANIZER. Contact Name: Phone	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

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