Name of Requestor   

Your Organization

CONTACT INFORMATION

        Telephone Number

        Address #1

        Address #2

        City

        State                                             Zip Code

        E-mail Address

Date Speaker is Needed

Time Speaker is needed

AM            PM

Location of Event

Desired length of talk

Topic of talk

Audience Description (Example: Senior Citizens, Elementary students, veterans, etc)

Additional Pertinent Information

Forward this Request to one of the following (please place the name of the person you want to send this form to in the box below)

Wally Mueller              410-838-5496      kitandwally@yahoo.com

Ed Kreiner                   410-803-7177      edtkreinersr@comcast.net

Elizabeth Kruger        410-515-0941       BKr411@aol.com