JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Speaker Request
Please complete the form below. A representative from Wisconsin Democracy Campaign or the Wisconsin Fair Maps Coalition will contact you as soon as possible.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Organization Requesting Speaker
*
Your answer
Contact Person:
*
Your answer
Phone number:
*
Your answer
Email address:
*
Your answer
Date of Event:
*
MM
/
DD
/
YYYY
Time of Event:
*
Time
:
AM
PM
In-person or virtual
*
Choose
In person
Virtual
Other
Purpose/focus of event:
*
Your answer
Topic of event - Please select a MAXIMUM of two topics.
*
Gerrymandering/Redistricting
Constitutional Amendments/Direct Democracy
Money in Politics
Access to voting/Voter Suppression
Racial Equity/Economic Justice
Judicial Integrity
Other
Required
Requested speaker (not guaranteed):
*
Choose
Iuscely (Cely) Flores (Milwaukee area), WI Democracy Campaign & WI Fair Maps Coalition - fair maps; constitutional amendment questions; access to voting; Racial Equity/Economic Justice (English and/or Spanish)
Debra Cronmiller, League of Women Voters - fair maps; constitutional amendment questions; access to voting; judicial integrity
Nick Ramos, Wisconsin Democracy Campaign - fair maps; constitutional amendment questions; access to voting; money in politics; racial equity/economic justice; judicial integrity
Carlene Bechen, Retired Organizing Director, Wisconsin Fair Maps Coalition; Chair, LWV Ad Hoc Redistricting Committee; fair maps, constitutional amendment questions; access to voting; money in politics
Penny Bernard-Schaber, Common Cause in Wisconsin - fair maps
Hans Breitenmoser (Northern Wisconsin) - fair maps
Other/Unsure
Please describe the format for the event:
*
Your answer
When do you need confirmation?
Your answer
Other details or questions:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
