State of New Jersey

Event Speaker Request Form

Date of Event (mm/dd/yyyy)

Title of Event:

Event Location

Address 1
Address 2
City
State
- Zip Code
County

Beginning/Ending Time of Event

Beginning/Ending Time of Speaker's Participation

Event Sponsor

Contact Person's Name Prefix

Contact Person's First Name

Contact Person's Last Name

Suffix

Contact Person's Title

Either an e-mail address or a street address must be entered.
The more information you give us, the better we can serve you.

Contact E-Mail Address

Contact Street Address

Address 1
Address 2
City
State
- Zip Code
Country

Contact's Phone Number

ext. 123-456-7890 ext. 12345

Contact's Fax Number

Contact's Cell Number

123-456-7890

Organization's Website

How were you referred to our agency?

Who are you requesting as your speaker? If "Other" identify name of requested speaker
or type of speaker needed (i.e., attorney, investigator, etc.).
Director Frank Vespa-Papaleo
Other

If the Director or the requested employee is unable to attend, would you like us to attempt
to secure another Division employee as a replacement speaker or panelist?
Yes
No

Provide a copy of the event invitation or flyer and describe nature of event:
Seminar
Swearing-in
Conference
Awards ceremony
Group meeting
Other

Remarks

Provide the format of speaker's participation:
Keynote
Moderator
Welcoming/Greetings
Substantive training
Panelist
Q&A
Other

Remarks

Describe the topic(s) you would like the speaker to address .

Who will be introducing the speaker?

Provide your RSVP deadline if any:

Please provide the anticipated size of audience:

Is this a partisan/political event?
Yes
No

Cost per attendee ( face value of the event ticket and /or estimated cost per attendee to
the sponsoring organization.):

Will any meals, food or drink be provided to attendees during the event?
Yes
No

Except for nominal refreshments such as non-alcoholic beverages and light snacks,
list any meals, food and drink?

Are the sponsors, underwriters, co-sponsors or event organizers offering to pay, waive
or reimburse for event or registration fees, costs of travel, meals, accommodations,
or other costs associated with the Division employee attending the event, and is this
offered to all other invited speakers?
Yes
No

If yes, please specify:

Is the event a fund-raiser?
Yes
No

If yes, provide the name of the recipient(s)

Will anyone besides the person requested from the Division be speaking at this event?
Yes
No

List all organizers, sponsors and co-sponsors of the event, and for each organizer,
sponsor or co-sponsor, answer the following questions:

Are any press or media representatives expected to be in attendance? If so, provide
the name and business or organizational affiliation of each press or media representative,
and provide name and contact of the person who handles press relations for your event/organization:

a.	Is it a: Non-profit organization? Government agency? Other? (describe the nature of the business entity - e.g. corporation, partnership, etc.)
b.	Does it have any contracts with the State of New Jersey?
c.	Is the organizer, sponsor or co-sponsor a named party or the representative of a named party in a complaint, case, appeal or other matter involving the New Jersey Division on Civil Rights? Yes No If so, provide the name and docket number or otherwise describe the matter.
d.	Does the organizer, sponsor or co-sponsor advocate or represent the positions of its members to the Division on Civil Rights? Yes No

Date

Signature

If you would like to provide any additional information do not hesitate to attach it to this form and fax or
email it to the above address. Thank you.