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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date 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.) Are presentation materials (i.e. PowerPoint slides or other visuals) requested?YesNoAnticipated audience sizeOpen to press?YesNoAre there additional (i.e. prep calls) If so, what is the estimated duration and time/date?Meeting Participants Enter each participant on a new line: Name/Title/Representing Note: If you are a lobbyist or government relations representative please list the all technical, legal, and other colleagues who will attend the meeting with you.Point of contact on day of meeting: First Last Point of contact cell phone number:NameThis field is for validation purposes and should be left unchanged.
