ELECTRONIC SPEAKER REQUEST FORM
Authorized by PA 451 of 1994, as amended.
Completion is voluntary.


The Office of Environmental Assistance Speakers Bureau coordinates requests for environmental speakers. Each inquiry is carefully evaluated to identify the needs of the audience and determine the most suitable presenter. Requests for speakers are given prompt, courteous attention and filled in a timely manner. Please submit event information at least one month prior to the event date.  To request a speaker, submit the following information or contact Anita Singh at (517) 284-6877 or e-mail singha3@michigan.gov.

* You must enter information in these fields before submitting your request. 

 * Requestor's Name:
Title:
Company:
Address:
City:
State and Zip Code:   
 * Phone (Area Code/Number):
FAX (Area Code/Number):
E-mail:
Trade Association or Group Affiliation:
If you are submitting this request on behalf of an association, please enter the name of association.
 * Name of Event/Speaking Engagement 
Please enter name of event.
 * Event Location:
 * Event Date:
 Audience Profile: 
Please enter description.
Is this a K-12 school audience?
Estimated Number of People Attending Event:
 Start Time:
End Time:
 * Presentation Topics/Content Requested:
Please enter the environmental topic(s) the presentation should address.
 * Deadline Date for Response:
Please enter the date you would like for us to inform you whether we can or cannot fill this request.
 

EQP 3568 (6/98)