PRESENTATION REQUEST FORM
Request Date:
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Requester's Name:
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Prefix
First Name
Last Name
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Organization:
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Type of Organization:
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Non-Profit
For-Profit
Governmental Entity
Requester Primary Contact Number:
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Area Code
Phone Number
Requester Secondary Contact Number:
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Area Code
Phone Number
Requester Contact Email:
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Requested Presentation Date:
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Month
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Year
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Time of presentation:
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Hour
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10
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50
Minutes
AM
PM
AM/PM Option
Presentation Title:
Allotted presentation time:
Presentation Location:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
This presentation request is for:
Performance-Art Presentation
Conference Workshop
Keynote Presenter
Presentation- School/University
Presentation- Inservice Training
Community Presentation
Resource Distribution
Church Presentation
Select the group you are requesting to PRESENT/PERFORM:
Distinguished Gentlemen of Spoken Word
Community Boys Band
Bethune Girls Poetry Group
Be My DFF Team
Circle for Reentry Ohio (CFRO)
Senior Adult Aiming High
Minority Youth Leadership Council
Women Recovery Services
Select a topic area that you want addressed Drugs (Please specify, i.e. alcohol, marijuana, heroin, etc)
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Please indicate if the following will be provided:
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Please identify the venue description that best fits your :
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Projected Demographics:
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Age (Select each age group that apply, and project how may expected in each age group add more if needed)
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Any Special Comments or Inquiry:
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