Speaking Request Form Senator Aument's Speaking Request Form Name of Organization(Required) Date(s) and time of event (Please include approximate time on the agenda you are requesting the Senator to speak)(Required)Location/address of event/parking (To process this request, please include building name, street, city, county, state, zip code and available parking)(Required)Name and brief description of Event (i.e. Annual Meeting, Conference, Seminar, Board Meeting, etc.)(Required)Speech Format (i.e. Keynote Address, Seminar, Panel Participant, etc.)(Required)Contact(Required) First Last Contact Title Contact Cell Phone(Required)Contact Work PhoneContact Email(Required) Have you extended this speaking request to any other Pennsylvanian government staff?(Required) Yes No (if yes, please indicate names of anyone else you have asked to speak, including those who accepted, and the POC to whom you submitted that request)Speech/PowerPoint/Talking PointsProposed topic for speech(Required) Length of speech time requested?(Required) Is a PowerPoint presentation appropriate?(Required) Yes No If so, will setup be provided? Yes No Do you require slides prior to event? Yes No Will Question and Answer (Q&A) session follow?(Required) Yes No Please provide information on who will introduce the Senator (bio if available)(Required)Is there anyone specific the Senator should recognize and/or thank? (i.e. event organizer, special guests)(Required)Please provide information on event set up (i.e. podium, auditorium, banquet room, type of microphone)(Required)Audience/Attendees/SpeakersAudience profile (i.e. Industry, Academia, Advocacy Groups, Business Executives)(Required)Are there other state or federal officials such as PA state legislators, Congressional Members or any other VIP officials expected to attend? (if yes, please list names and titles)(Required)Expected number of attendees for this speech(Required) Is this event open to the public or invitation only?(Required) Public Invitation Only Is there an admission charge for attendees or speakers?(Required) Yes No (if yes, please indicate how much per person) Will there be any refreshments/snacks/meals served at event? Media InformationIs this event open or closed to the media?(Required) Open Closed Will there be a request for the Senator to address media before or after the event? (if yes, please provide additional details)(Required)If media is invited will you be “advertising” prior to the event?(Required) Yes No What media outlets will be utilized?