If you are interested in requesting a speaker for your upcoming event, please complete this form or contact Kathryn Verlin, (913) 588-5240.

Contact Information

Name *	Middle	Last *
Phone # *	Fax #	Email*

Event Information

Title of Event * 03/15/2006 Date of Event * Monday, Tuesday, etc...
Day of Event *	Begin Date *	End Date *

Place of Event

Street Address * Building - Room - Suite
City *	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	Zip *

Expectations

Attendance * # of people attending Type of Audience * volunteers, business leaders, etc... Expectations Example: "David will perform as master of ceremonies." or "We'd like David to speak for 10 minutes on how a bill becomes a law."