Please enter all information below Completing this form does not commit the Department to a specific speaking engagement. Upon completion, the Public Information Officer will contact you with a a decision regarding your speaker request. For confirmed speaking engagements, the Department reserves the right to substitute an alternate speaker should a scheduling conflict arise beyond the control of the scheduled speaker. Thank you for your interest in having a speaker from the New Mexico Environment Department at your event! Name of Requester* First Last Organization* Requester Title* Requester Email* Requester phone*Event title Event website Presentation/Remarks themes* Speaker requested Is an alternate speaker acceptable?YesNoWill the NMED speaker be participating:*VirtuallyIn PersonEvent location Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred date/time? MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Second Preferred date/time? MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Duration of NMED participation* Is time flexible?YesNoFormat* (i.e., Panel, Keynote, Lunch Speaker, etc.) If applicable, names and affiliations of additional panelistsAre presentation materials requested (e.g., PowerPoint slides or other visuals)?*YesNoAnticipated audience size*Open to press?YesNoAre additional pre-meetings required (e.g., prep calls)? If so, what is the estimated duration and date?*Point of contact on day of meeting: First Last Point of contact cell phone number:PhoneThis field is for validation purposes and should be left unchanged.