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26th LD Democrats Speaker Request Form

Please note that you must complete and send this form without closing it. Any and all information entered will be lost when you migrate away from this page, close your browser, or shut down your computer.

Speaker's Topic (Select from drop-down list):

Today's Date:

May 19, 2012

Speaker's Name:

Speaker's Company, Association, or Affiliation:

Your Name (if different):

Home Address:

City: State: ZIP Code:

Phone:

Alternate Phone:

Cell Phone:

E-mail Address:

Other E-mail Address:

Availability

During which monthly meeting would you like to speak? Check all that apply. Note: We meet the first Tuesday of the month; we do not meet in some summer months or on election day. Further, we do not necessarily have a guest speaker at each meeting:











Special Equipment

For my presentation, I would like to have (check all that apply):





Special Skills or Qualifications

Summarize speaker’s special qualifications acquired from employment, education, volunteer work, or through other activities, including hobbies or sports. This information will be used to introduce our guest speaker.

Finally, any additional comments you would like to share with the Executive Board:



The 26th Legislative District Democrats welcome all guests without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. By clicking the "Submit" button, below, I affirm that the facts set forth in this form are true and complete. I understand that if I am accepted as a speaker, any false statements, omissions, or other misrepresentations made by me on this application may result in immediate cancelation of my place on the agenda.

 If you would like a copy of the completed form sent to you, please enter your e-mail address here:  

"Submit" sends the form. "Clear Form" clears all fields in the form.

If you wish to keep a copy for your files, either print or save the form before submitting or clearing it.

Do you wish to be a guest speaker?

Please fill and Submit the form at left.

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