Department of Defense Cyber Crime Center Speaker Request Form

							                       DEPARTMENT OF DEFENSE CYBER CRIME CENTER
                                SPEAKER REQUEST FORM


1. REQUESTOR’S NAME            2. DATE                                     3. PHONE NUMBER

4. ORGANIZATION NAME           5. ORGANIZATION MAILING                     6. FAX NUMBER
                               ADDRESS


7. EVENT DATE

8. EVENT LOCATION (i.e. State, City, Hotel, and Conference Center)

9. EVENT TYPE (i.e. Conference, Training Seminar, Working Group, etc)

10. EVENT AUDIENCE (i.e. Federal, State, Local Government, Law Enforcement, System Administrators, etc)

11. SPEAKER REQUESTED

12. PRESENTATION TOPIC

13. PRESENTATION START DATE/TIME

14. PRESENTATION LENGTH

15. PRESENTATION AUDIENCE

16. TRAVEL EXPENSES (i.e. reimbursed, not reimbursed)

17. MEDIA PRESENCE (i.e. Type of Media, Specific Organizations, etc)

18. ADDITIONAL INFORMATION


19. COORDINATION (INTERNAL USE ONLY)
      DATE                     TO                                        ACTION                           INITIALS