Agency Speaker or Tour Request Form

To be completed by the person that is making the request:
Do you want to request a Speaker or a Tour?*
- Speaker
- Tour
Speaker Request
Date of presentation*
Time of presentation*

: HH

MM
Workplace requesting*
Level*
Purpose of presentation (committee/ECC training/presentation to employees, etc.)*
Estimated number of people in audience*
Address for presentation*
Directions or instructions, (i.e. where to meet)
Speaker, Agency or Impact Area Requested:
Choice #1
Choice #2
Choice #3
Staff/LR making request*
Request approved by*
Date of request*
Is the attending staff/LR the same as above?*
- Yes
- No
Who is the attending staff/LR?*
First Last
Additional comments
Tour Request
Date of Tour*
Start time
End time
Who is the custom tour for? (Workplace/Group)*
How many people are expected to participate?*
Request approved by*
Date approved*