Speaker Request Form | Pierce County | Washington State University

Group requesting speaker*
Date of Event*
MM slash DD slash YYYY
Day of the Week
Location of event
Name of facility or building
Room Number
Address*
Street Address City State ZIP Code
Contact Name*
First Last
Contact Phone*
Contact Email*
Facilities Phone*
Desired length of presentation*
Time of presentation*

: Hours

Minutes

AM/PM
Type of presentation*
Presentation Equipment needs*
- LCD
- Audio
- Screen
- Flip-chart
- None
Presentation topic(s) requested*
WSU Extension is supported by public funds and adheres to civil rights laws and regulations. Extension can not provide services to any organization that discriminates. Please indicate by checking the box below that your organization does not discriminate on the basis of race, sex, religion, age, color, creed, national or ethnic origin; physical, mental or sensory disability; marital status, sexual orientation, and status as a Vietnam-era or disabled veteran and provides reasonable accommodations for access to individuals with disabilities and special needs.
- Organization meets this criteria