Democrats for Change Speaker Request Form
Use this form to invite Lisa McCormick or request another Democrats for Change representative to your event.
Email address
First name
Your answer
Last name
Your answer
Company/Organization
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Title
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Phone
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E-mail Address
Your answer
Organization or Event Website URL
Your answer
Event Name
Your answer
Location (Venue Name)
Your answer
Location (Address, City, State, Zip)
Your answer
Event Start Date
MM
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DD
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YYYY
Event Start Time
Time
:
Event End Date
MM
/
DD
/
YYYY
Event End Time
Time
:
Requested Speaker
Your answer
Surrogate speaker acceptable
Event Sponsors
Your answer
Event Agenda
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Invited Speakers
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Confirmed Speakers
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Audience Demographics
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Number of Expected Attendees
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Can you attend?
Is this time slot flexible and/or tentative?
Format of Event
Let us know what format
Q & A Included?
Are press invited?
Will session be recorded?
Is the public invited to attend?
Is there any other information you would like us to know to evaluate this request?
Your answer
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