Organization Name. Office Phone. Mobile Phone. Is the Primary Contact the same as the "Day of the Event" Contact? Yes No. Host Organization. Type of Organization Please select State Association Regional Association HS Program Other.

If other, please provide details below. Name of Event please include a brief description. Event Start Date. 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. What topic or subject are you interested in hearing about from this person?

Are you open to an alternative speaker from Patagonia if your top choice is not available? Have you requested a speaker from Patagonia for this same event in years past? If yes, from which years?

Will media be in attendance? If so, who? Has this event received any press attention in the past? If yes, please include a few links to past press coverage. Did a Patagonia employee refer you? Yes No. 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.

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 take a moment to complete the Please send the completed form to the DOD CIO Speaker Requests Mailbox: osd 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 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

If yes, please provide Speaking Engagement Request Form. Speaking Start Forj. The location should include Venue, City, and State. Phone Required. Today's Date. CAPT Emily Williams, LCSW-PIP, BCD Hal Zawacki, M.	Looking for a speaker from NITAAC to engage with your audience? Event Location Required. Please know we do our best to read all requests in a timely manner. Phone Number. Closest Airport to the Event.	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	Use the Speaking Engagement Request form if interested in having a PMI Board member or executive staff member present at your event 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	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
gov website belongs For an official government organization in the United States. Speakign of Organization Please select CAPT Emily Williams, LCSW-PIP, BCD Hal Zawacki, M. Organization Website. NOTE: CRD staff cannot accept speaker fees, honorariums, or travel expenses.	Hotel Name 1. Please include who should receive invoicing usually days, post event. Birmingham City Council Facebook Twitter YouTube Instagram. Are you expecting any distinguished guests at this event? Home About Live City Council Work City Directory Play 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	Looking for a speaker from the Illinois Judicial Speakers Bureau? Complete the Illinois Courts' Speaking Engagement Request Form 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	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
Engsgement City. Event Topic. Deadline to receive speaker confirmation Deadline to Speaking Engagement Request Form speaker Spraking Date. All meeting and speaking requests must be submitted through the web form below. Does the hotel have shuttle service to and from the airport?	Cell Phone. Tom Coderre Sonia Chessen Trina Dutta Michelle Greenhalgh Larke Nahme Huang, Ph. Event Venue. Lucia St. Select an alternate speaker below Please select	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 ArcGIS Survey is a complete, form-centric solution for creating, sharing and analyzing surveys Birmingham, Alabama: Putting People First · Speaking Engagement/Event Request Form · All forms should be completed and submitted at least 21 business days in	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

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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

We cannot guarantee a response any earlier than four weeks before the requested date. A letter confirming receipt of your request will be emailed to you after submission. For more questions please direct them to engagement samhsa.

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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. Will this event be virtual or in-person? Is this for a keynote, panel or fireside chat? What topic or subject are you interested in hearing about from this person? Are you open to an alternative speaker from Patagonia if your top choice is not available?

Have you requested a speaker from Patagonia for this same event in years past? If yes, from which years? Will media be in attendance? If so, who? Has this event received any press attention in the past? If yes, please include a few links to past press coverage. Did a Patagonia employee refer you?

Yes No. If this is an in-person event, are you able to cover expenses for the Patagonia employee to attend? Is there a ticket cost for people to attend this event?

If so, are you willing to provide tickets to Patagonia employees at no cost?