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WSNCT Speaker Request
Event Name
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Begin Time
End Time
Event Purpose/Description
Organization Holding Event
Event and/or Organization Website
Organization Background/Description
Primary Contact Name
Primary Contact Company Name
Primary Contact Title
Primary Contact Phone Number
Primary Contact Email
Audience Information - Expected Attendance
Audience Information - Demographics
Suggested Topic for Remarks
Suggested Length of Remarks:
Other Speakers Who Are Participating in the Event
Will the speaker be on a stage?
Yes
No
Will a podium be available
Yes
No
Will there be a backdrop, signage or screen image behind the speaker?
Yes
No
Will A/V be available for a PPT presentation or video?
Yes
No
Will members of the media be present?
Yes
No
OPTIONAL - Please attach the proposed meeting agenda/event program.
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