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Request for Presentation
Topic:
(Topic you wish to be discussed)
Date(s):
(Dates you would like the presenter to present topic)
Alternate Date(s):
(Dates you would like the presenter to present topic if first choice is not available)
Time(s):
(Times you would like the presenter to present topic)
Alternate Time(s):
Program Site:
(Place where presenter arrives to present the topic)
Contact Person:
Phone No.:
(Where contact person can be reached)
Alternate No.:
Organization:
(Description of attendees being addressed: i.e.: class, hall, program, etc.)
Number of Participants:
(Estimated Number of Participants)
Type of Service:
Sexual Assault
Domestic Violence
Helping a Friend
Peer Educators
Dating Violence
