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
Your answer
Phone *
Your answer
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 *
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DD
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YYYY
Event Start Time *
Time
:
Event End Date *
MM
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DD
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YYYY
Event End Time *
Time
:
Requested Speaker
Your answer
Surrogate speaker acceptable
Event Sponsors
Your answer
Event Agenda
Your answer
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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