Parole Board Speaker’s Request Form

Please submit form at least 4 weeks before scheduled event.

Describe Event (required)

Event Name (required)

Affiliated Organizations

(if applicable)

Event Date (required)

Event Location (required)

Address (required)

City (required)

State (required)

Location Phone (required)

(###) ###-####

Location Fax

(###) ###-####

Event Contact Person

Event Contact Person

Name (required)

Title

Work Phone (required)

(###) ###-####

Cell Phone

(###) ###-####

Home Phone

(###) ###-####

Email (required)

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Local Media Contact (required)

Phone (required)

(###) ###-####

Event Information

Event Information

Requested Board Member or Staff Member (required)

Parole Board Member’s Role at the Event

Features Speaker / Guest

Introduced and Brief Remarks

Greeting

Forum / Panel

Purpose of the Event (required)

Key issues of importance to the organization and/or specific issues that the group would like the Board Member or staff to address (required)

Length of remarks expected from Board Member (required)

Event Attendees

Event Attendees

Number of Attendees (required)

Open to Public?

Yes

No

Media to attend?

Yes

No

Other Speakers at the Event

Other Speakers at the Event

Name

Title

Name

Title

Name

Title

Name

Title

Persons to be seated with the Board Member

Persons to be seated with the Board Member

Name

Title

Name

Title

Name

Title

Name

Title

Who will introduce the Board Member or staff?

Who will introduce the Board Member or staff?

Name

Title