Speakers Request Form

Governor’s Office of Small, Minority & Women Business Affairs

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Thank you for your interest in having a representative from the Governor’s Office of Small, Minority &
Women Business Affairs participate in your upcoming event. Please complete and submit the following
form (and any corresponding attachments) to [email protected], at least four (4) weeks
prior to the event. Allow 3-5 business days for decisions to be made. If you have any questions or need help completing the Speaker Request Form, please call Eduardo Hayden at 410-697-9606.

1.	First Name:*

2.	Last Name:*

3.	Phone Number:*

4.	Email:*

5.	Organization: *

6.	Event Name/Description:*

7.	Event Date & Time:*

8.	Event Location/Region:*

9.	Address: Street, City, State, and Zip Code*

10.	Number of People Expected:*

11.	Business Topic/Theme:*

12.	Speaker Role:*

13.	Speaker Time (start & finish): *

Submit