Speaker Request Form

Name:*
First Last
Address:*
Street Address Address Line 2 City State ZIP Code
Phone:*
Email:
Tell us about your organization/group:
Approximate number of attendees:*
Please enter a number greater than or equal to 1.
Approximate length of talk:*
Want to learn more about our speakers before you select one for your event? Learn More About Our Speakers
Request your speaker:*
- Steve Rupp, President
- Susan Klein, Executive Director & Chief Lobbyist
- Therese Sander, Vice President
- Jim Cole, General Counsel
- Gerard Nieters, Legislative Director
- Pam Fichter, MRL Eastern Region Chair
- Patty Skain, Assistant to the Executive Director
Select the date of your event:*
MM slash DD slash YYYY
Select the time of your event:*
: Hours
Minutes
AM/PM
Topic:*
Materials needed:*
Phone
This field is for validation purposes and should be left unchanged.

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